Walden - NURS 6512 Week 8 Discussion - Assessing Musculoskeletal Pain

Week 8: Assessment of the Musculoskeletal System

A 46-year-old man walks into a doctor’s office complaining of tripping over doorways more frequently. He does not know why. What could be the causes of this condition?

Without the ability to use the complex structure and range of movement afforded by the musculoskeletal system, many of the physical activities individuals enjoy would be curtailed. Maintaining the health of the musculoskeletal system will ensure that patients live a life of full mobility. One of the most basic steps that can be taken to preserve the health of the musculoskeletal system is to perform an assessment.

This week, you will explore how to assess the musculoskeletal system.

Learning Objectives

Students will:

Evaluate abnormal musculoskeletal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system

Learning Resources

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
Chapter 22, “Musculoskeletal System”

This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 22, “Lower Extremity Limb Pain”
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

Chapter 24, “Low Back Pain (Acute)”
The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)
Chapter 3, “SOAP Notes”

This section explains the procedural knowledge needed to perform musculoskeletal procedures.

Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.

This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.

Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010

Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002

Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)

Optional Resource

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)

In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.

Required Media

Musculoskeletal System – Week 8 (12m)

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/

Discussion: Assessing Musculoskeletal Pain

The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.

In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To prepare:

By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
Review the following case studies:

Week 8 Assignment Sample Paper

NURS 6512 Week 8 Discussion – Assessing Musculoskeletal Pain

Assessing Musculoskeletal Pain

Student’s Name:

Institutional Affiliation:

Musculoskeletal pain is a common phenomenon of which nearly everyone has to experience at a given point in their lives. There are different causes of musculoskeletal pain, but the most common causes are trauma, strain from daily activities and diseases (Baker et al., 2017). The regions that may elicit pain are the muscles, joints, bones, and periarticular tissues but the impact depends on the severity and nature of injury. In assessing a patient with Musculoskeletal pain both subjective and objective approaches are used for proper diagnosis and treatment. The caregiver has to assess the current symptoms of the patient, how it evolved, surrounding factors, and the impact of the problem on the individual’s health and quality of life. This paper aims to conduct a review of an ankle pain case study of a soccer player to assess her condition and recommend the right treatment.

Episodic/Focused SOAP Note

Focused SOAP Note for a patient with ankle pain.

Patient Information

The patient is a 46-year-old white female

Chief complaint: Ankle pain

The patient visited complaining of pain in both legs, mainly within the ankle areas. Her most significant concern was with her right leg. She explains that she felt a pop in the ankle region during a game of soccer. From a general view when she entered, she can bear her weight but she is limping uncomfortably. The patient does also look stressed and fatigued.

HPI: Using LOCATES.

Location: Leg, right ankle
Onset: 2 days ago
Character: Uncomfortable pain, popping sound at the heel during injury, difficulty walking and moving the ankle, limping.
Associated signs and symptoms: Swelling, stiffness, ankle at odd angle, and inability to bear the body’s weight.
Timing: During a soccer match at the weekend.
Exacerbating/relieving factors: Uncomfortable pain when the region is subjected to the body weight when walking, palpated, or squeezed. The pain is reduced when the area is iced or at rest.
Severity: 8/10 pain scale

Current Medications: The patient was subjected to over the counter NSAIDs, with a dosage of Ibuprofen 200mg, one pill for every six hours for the past two days. The reason for taking the pills was to relieve the pain felt in the ankle. The patient had also tied the ankle region with a bandage for support. The patient did also take alcohol to sedate the pain.

Allergies: The patient has no history of any allergies, either for food or drugs

Soc Hx: The patient is a soccer player, married for 20 years, has negative use of tobacco or any smoking drugs, consumes a lot of coffee, and moderate alcohol.

ROS:

General- The patient seems to be in pain, stressed, and fatigued.
Cardiovascular–Negative of complicated heart conditions and diseases
Gastrointestinal–Positive for vomiting but it is after excessive alcohol intake; negative for stomach upsets and abdominal pain.

Constitutional – The patient admits to weight increase recently and frequent fatigue.

Eyes – no changes in vision; wears glasses only when reading.

ENT – Hearing is definite: does not wear hearing aids.

Skin/Breast – no allergies or rashes; Warm and red on the right ankle

Pulmonary – Easy to breathe in and out; no shortness of breath; no cough

Endocrine – Appetite still intact

Genito Urinary – No pain or irregularity in urination frequency. Some urge was due to alcohol intake; Negative of infections.

Musculo Skeletal – Changes in strength, pain in both legs, swelling, strain during walking.

Neurologic – Memory is unaffected

Psychology – Appears stressed, uncomfortable, and restless.

Heme/Lymph – Negative of easy bruising

Head to toe examination.

Vitals: Temp: 98°F BP: 125/86mmHg BMI: 28

General: The patient looks calm though stressed and fatigued, weight/ height are proportionate.

Skin: Warm, dry, well-perfused; No visible rashes, the right leg ankle region is swollen, with redness.

Extremities: positive lower extremity pain or edema when palpated; symmetric legs

Differential diagnosis

Broken ankle: The sudden sharp pain during the soccer match and a popping sound during the injury are likely due to a snap in an ankle bone (Fraser, Feger & Hertel, 2016). Supported by difficulty in walking and the oddness of the ankle angle could likely be a broken ankle.

Achilles tendonitis: This does also result in pain I the ankle and the heel region, and presents difficulty in walking or standing.
sprained ankle: With the intensity of a soccer match, the condition could be a sprain, supported by the symptoms of pain, swelling, repetitive exercise during the game, redness, and bruising.

Presumptive diagnosis: Broken ankle.

A thorough physical examination is required before proposing costly radiographic diagnoses and scanning. The Ottawa Ankle Rules have proven to be effective in assessing fractures of the ankle and near regions such as the midfoot (Beckenkamp et al., 2017). The procedure has proven to produce modest specificity and accurate sensitivity. Ottawa Ankle Rules is efficient as it saves time and costs of treatment, and with its diagnostic accuracy midfoot fractures and injuries on the ankle can be detected (Beckenkamp et al., 2017). The procedure can explore the involvement of soft tissues, ligament, tendons, and vertebral fractures.

Not applicable in this section.

References

Baker, S., McBeth, J., Chew-Graham, C. A., & Wilkie, R. (2017). Musculoskeletal pain and co-

morbid insomnia in adults; a population study of the prevalence and impact on restricted

social participation. BMC family practice, 18(1), 17.

Beckenkamp, P. R., Lin, C. W. C., Macaskill, P., Michaleff, Z. A., Maher, C. G., & Moseley, A.

(2017). Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic

review with meta-analysis. Br J Sports Med, 51(6), 504-510.

Fraser, J. J., Feger, M. A., & Hertel, J. (2016). Midfoot and forefoot involvement in lateral ankle

sprains and chronic ankle instability. Part 1: anatomy and biomechanics. International

journal of sports physical therapy, 11(6), 992.

Case 1: Back Pain

Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?

Case 2: Ankle Pain

Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.

A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?

Case 3: Knee Pain

Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.

A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

With regard to the case study you were assigned:

Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.

By Day 3 of Week 8

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

Read a selection of your colleagues’ responses.

By Day 6 of Week 8

Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 8 Discussion Rubric

Post by Day 3 of Week 8 and Respond by Day 6 of Week 8

To Participate in this Discussion:

Week 8 Discussion

Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination

A description of symptoms alone is not enough to form an accurate diagnosis of musculoskeletal conditions. Before forming a diagnosis, advanced practice nurses need to perform a physical examination. Although the musculoskeletal examination is relatively simple, it still needs to be performed multiple times before it can be mastered.

In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing a musculoskeletal examination this week.

Note: This is a practice physical assessment.

To Prepare

Arrange an appropriate time and setting with your volunteer “patient” to perform a musculoskeletal examination.
Download and review the Musculoskeletal Checklist provided in this week’s Learning Resources as well as review the Seidel’s Guide to Physical Examination online media.

The Lab Assignment

Complete the following in Shadow Health:

Musculoskeletal (Practice)

What’s Coming Up in Week 9?

Next week, you will examine appropriate methods for assessing the cognition and the neurologic systems during your Discussion. You also will complete the last assessment, Comprehensive (Head-to-Toe) Physical Assessment. Once again, you will conduct this assessment in the Digital Clinical Experience using the simulation tool, Shadow Health. Make sure to plan your time accordingly.

Week 9 Required Media

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time.

Next Week

To go to the next week:

Week 9

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Walden – NURS 6512 Week 8 Discussion – Assessing Musculoskeletal Pain