NURS 6512 Week 8 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 provide 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.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive
SOAP data are included in every patient case.
Case 1: Back Pain
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 is your differential diagnosis 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?
Note: Please view the Week 8 Discussion area to view the image for Case Study 1.
Case 2: Ankle Pain
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?
Note: Please view the Week 8 Discussion area to view the image for Case Study 2..
Case 3: Knee Pain
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?
Note: Please view the Week 8 Discussion area to view the image for Case Study 3.
To prepare for NURS 6512 Week 8 Discussion Assignment:
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
Post a description of the health history you would need to collect from the patient in the case study to which you were assigned. Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Include how the patient X-ray helped you to refine the differential diagnosis.
Read a selection of your colleagues’ responses.
By Day 6
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.
NURS 6512 Week 8 Quiz
- A 7-year-old boy is brought into your office with a chief complaint of a possible fracture in his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response?
- A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?
- Classic carpal tunnel syndrome would result in:
- A tingling sensation radiating from the wrist to the hand on striking the median nerve is a positive _____ sign.
- A red, hot swollen joint in a 40-year-old man should lead you to suspect:
- The usual number of vertebrae is:
- In differentiating osteoarthritis from rheumatoid arthritis (RA), the osteoarthritis patient typically exhibits:
- The physical assessment technique most frequently used to assess joint symmetry is:
- During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the _____ test.
- Light skin and thin body habitus are risk factors for:
- Risk factors for sports-related injuries include:
- An adult with bowed tibias and a shortened thorax may have:
- Ligaments are stronger than bone until:
- An increase in muscle tone is known as:
- A goniometer is used to assess:
- When the patient flexes forward at the waist, what spinal observation would lead you to suspect scoliosis?
- The dowager hump is:
- You note that a child has a positive Gower sign. You know that this indicates generalized:
- The elasticity of pelvic ligaments and softening of cartilage in a pregnant woman are due to:
- Injuries to long bones and joints are more likely to result in fractures than in sprains until:
Assessing Musculoskeletal Pain Sample Paper
The patient is a 42-year-old male who reports to the health facility.
The man complains of lower back pain that he has been experiencing for the past one month.
History of Presenting Illness
A forty-two-year-old male patient was well until about a month ago when he started experiencing lower back pain. He describes the pain as being located in his lower back region, a problem that began about a month ago and radiating to his left leg. It would be important to describe the character of the pain. Knowing whether it is a pounding, stabbing or sharp pain goes a long way in establishing a diagnosis.
The timing of the pain would also be important. It is worse during the day, at night or after completion of certain tasks. It would be important to highlight any exacerbating and relieving factors of the pain. Asking the pain to gauge the severity of his pain in accordance to the pain scale numbered one to ten would also be important to note while taking the history of the patient.
It is vital to look out for other associated symptoms commonly accompanying lower back pain. Weakness, numbness or any tingling sensation in the legs is important to note. It is vital that the patient points out the specific regions, if any, where he is experiencing weakness, numbness or a tingling sensation (Hartvigsen et al., 2018). Any associated fever along with the back pain would be critical to note as it would be an indicator of an infection. Problems controlling bowel and bladder movements are other commonly associated symptoms of lower back pain that are important to ask about and note.
Nerve roots involved
A lumbar radiculopathy also referred to as sciatica occurs following involvement of the nerve roots responsible for formation of the sciatic nerve. The nerve roots exiting from the lower lumbar and upper sacral regions involve L4, L5, S1, S2 and S3 (Berthelot et al., 2018). Lower back pain is usually the commonest presentation of lumbar radiculopathy. The pain is often radiating to the back of the leg with sciatica commonly affecting one side of the body.
Testing for the nerve roots.
To test for the L4 nerve roots, one would test the loss of sensation in the dermatome supplied by L4. This includes the area around the thigh, knee, leg and foot anteromedially. It is important to also conduct the straight leg raise test, the femoral nerve stretch test, the knee reflex and to test the power of the muscle involved in ankle dorsiflexion to test for the credibility of the L4 nerve root.
The test for the L5 nerve root involves testing for the presence or absence of sensory sensation in the dermatome area supplied by L5. This area includes the buttocks, posterior and lateral aspects of the thigh, lateral part of the leg, dorsum of the foot, medial half of the sole including the first, second and third toes. It would also be advisable to conduct the straight leg raise test and test for the power of the muscle on hip abduction, dorsiflexion at the ankle, ankle eversion and extension of the big toe.
Testing for the S1 nerve roots involves testing for sensory loss in the dermatome area supplied by S1 (Tampin et al, 2020).. This includes the area around the lateral aspect of the foot, the heel and majority of the area of the sole. It would be important to carry out the straight leg raise test, ankle reflex and test for power of muscles involved in extension of the hip, knee flexion, plantarflexion at the ankle joint and ankle eversion.
Testing for dermatomes is usually done using a pin and cotton wool. The patient is asked to close their eyes and give a response after stimulation by various stimuli. Dermatome testing should be conducted on specific dermatomes and the results compared with the opposite side. The pin prick test involves gently pricking the patient with a pin and asking for the patient’s feedback whether it is a sharp or a blunt pain. Light touch sensation test involves rubbing a piece of cotton wool against a specific area on the skin.
The straight leg raise test is a neurodynamic test conducted to assess mechanical movement of the neurological tissues and their sensitivity to mechanical stress (Parashkevova et al., 2019). Testing is conducted on both lower limbs with the normal limb being assessed first. Patient lies in a supine position with the hip medially rotated and the knee extended. The physician then elevates the patient’s limb by the posterior ankle with the knee maintained in full extension continuously until the patient complains of discomfort at the back or posterior surface of the leg.
The femoral nerve stretch test is a test used to assess the sensitivity to stretch of the soft tissue located at the dorsal aspect of the leg. The patient is asked to lie down while the physician lies on the affected side to stabilize the pelvis and hinder any anterior rotation using one hand. The physician then proceeds to extend the hip while maintaining the knee at flexion. The physician can encompass a few alterations to the test position to be able to pick out the nerve involved.
Some of the causes of lower back pain include: sciatica, lumbar herniated disc, piriformis syndrome and arachnoiditis (Thompson et al., 2020). Sciatica often arises from a herniated disc. This results in compression of the nerve roots of the sciatic nerves that run from the lower back down to the lower limbs. Patients will normally present with lower back pain that is normally radiating to the back of the leg. A burning sensation, muscle weakness and bladder and bowel incontinence are among other presentations.
A lumbar herniated disc is a ruptured disc at the lower back normally arising as a result of a tear resulting in consequent pushing out of the nucleus out of the spinal disc. The protruding disc pushes against a spinal nerve resulting in severe pain, numbness and in some instances weakness. The pain is exacerbated by standing, coughing or sneezing and there is consequent reduction of reflexes at the knee and ankle joint.
Piriformis syndrome results from compression of the sciatic nerve by the piriformis muscle. It results in associated pain radiating to the lower leg, tingling and numbness in the gluteal region. Arachnoiditis, an inflammation of the arachnoid covering the spinal cord nerves, can also result in lower back pain radiating to the legs as the commonly affected nerves are in that region.
The Agency of Healthcare and Research and Quality lists back pain as a common occurrence affecting eight out of every ten individuals. It further goes to highlight that back pain can range from a dull, constant ache to a sudden, sharp pain (Herman et al., 2019). Acute back pain lasts a few days to weeks becoming chronic if it persists for a duration longer than three months. Over the counter medication and adequate rest are the remedies for most back pain with medical attention required if back pain persists.
Any physical exam begins with inspection. It is important to note the shape of the spine. Appreciate the normal curvature of the spine. The absence of lumbar lordosis is commonly associated with lower back pain. Palpation is the next step. Palpating the spinal region to elicit any tenderness helps to prove or rule out pain from the vertebra. Palpation of the para-spinal region to elicit tenderness proves muscle involvement. The next step is to conduct specialized tests.
Provocative tests are done to elicit any tenderness and pain. If these tests are positive, there is likelihood that the irritation on the nerve is as a result of mechanical interference resulting from a vertebral bone or herniated disc. Some of the special maneuvers include the straight leg raise test, the tripod sign and femoral stretch test. Neurological exams including motor, sensory and reflex exams can also be done. The major nerve roots examined are L4, L5 and S1 as they are the commonly affected nerve roots.
- Berthelot, J. M., Laredo, J. D., Darrieutort-Laffite, C., & Maugars, Y. (2018). Stretching of roots contributes to the pathophysiology of radiculopathies. Joint Bone Spine, 85(1), 41-45. https://doi.org/10.1016/j.jbspin.2017.01.004
- Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., & Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356-2367. https://doi.org/10.1016/s0140-6736(18)30480-x
- Herman, P. M., Broten, N., Lavelle, T. A., Sorbero, M. E., & Coulter, I. D. (2019). Health care costs and opioid use associated with high-impact chronic spinal pain in the United States. Spine, 44(16), 1154-1161. https://doi.org/10.1097/brs.0000000000003033
- Parashkevova, P., Deleva, R., Mincheva, P., & Andreev, A. (2019). A Study on Use of Neurodynamic Tests among Neurorehabilitation Professionals. Journal of IMAB–Annual Proceeding Scientific Papers, 25(1), 2438-2442. http://dx.doi.org/10.5272/jimab.2019251.2438
- Tampin, B., Slater, H., Jacques, A., & Lind, C. R. (2020). Association of quantitative sensory testing parameters with clinical outcome in patients with lumbar radiculopathy undergoing microdiscectomy. European Journal of Pain, 24(7), 1377-1392. https://doi.org/10.1002/ejp.1586
- Thompson, J., Merrill, R. K., Qureshi, S. A., & Leven, D. M. (2020). Compression of the S1 Nerve Root by an Extradural Vascular Malformation: A Case Report and Discussion of Atypical Causes of Lumbar Radiculopathy. International Journal Of Spine Surgery, 14(1), 96-101. https://doi.org/10.14444/7013