ASSESSING MUSCULOSKELETAL PAIN NURS 6512

Walden University ASSESSING MUSCULOSKELETAL PAIN NURS 6512-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University ASSESSING MUSCULOSKELETAL PAIN NURS 6512 assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for ASSESSING MUSCULOSKELETAL PAIN NURS 6512                     

Whether one passes or fails an academic assignment such as the Walden University ASSESSING MUSCULOSKELETAL PAIN NURS 6512 depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for ASSESSING MUSCULOSKELETAL PAIN NURS 6512                     

The introduction for the Walden University ASSESSING MUSCULOSKELETAL PAIN NURS 6512 is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for ASSESSING MUSCULOSKELETAL PAIN NURS 6512                     

After the introduction, move into the main part of the ASSESSING MUSCULOSKELETAL PAIN NURS 6512 assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for ASSESSING MUSCULOSKELETAL PAIN NURS 6512                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for ASSESSING MUSCULOSKELETAL PAIN NURS 6512                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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ASSESSING MUSCULOSKELETAL PAIN NURS 6512

Thank you for the information. Sciatica pain is a typical symptom of Lumber disc herniation (LDH), but some neurogenic and malignant tumors surrounding the sciatic nerve also cause a similar sign. The essential factors in the pathogenesis of LDH are occurred because of intervertebral disc degeneration, trauma, and genetic and developmental abnormalities. LDH symptoms are low back pain, sciatica, muscle weakness, sensory deficits, and never root tension signs, while sciatic nerve-derived tumors and surrounding neoplasm also show similar symptoms (Zhao et al., 2021).

Studies show that if patients present with back pain at rest, the possibility of tumors should be considered; proper imaging techniques should be used to prevent misdiagnosed with LDH. To avoid misdiagnosis, consistency between the clinical manifestation and radiological imaging findings, especially MRI results. According to Zhao et al., 2021, Sometimes sciatica caused by sciatic nerve tumors is only distal, without any radicular distribution. This pain is more severe than that caused by LDH, and this pain is not related to the position of the lumbar spine. Thus, performing a detailed physical examination of the sciatic nerve is beneficial to avoid this misdiagnosis.

Degenerative lumbar spinal stenosis (DLSS) is most commonly due to degenerative changes in the facet joint in an old individual. DLSS is a spinal canal narrowing that induces compression of the vascular structure and ischemia of the spinal nerves, leading to low back pain, leg pain, nervous claudication, disability, and loss of independence. Studies show that DLSS presented in up to 80% of adults aged 50 years or older. DLSS symptoms include pain in the groin, hips, and buttocks. DLSS impacted the ability to walk and move independently. DLSS can be diagnosed by MRI of the lumber spin, showing the atrophic muscles (Xia et al.,2021).

Another diagnosis test –

HLA-B27 -to determine the case of joint pain, stiffness, or swelling (blood test)

Erythrocyte sedimented rate (ESR) – is a blood test for joint pain or arthritis and muscle symptoms.

References

Zhao, L., Wei, J., Wan, C., Han, S., & Sun, H. (2021). The diagnostic pitfalls of lumbar disc herniation—- malignant sciatic nerve tumor: two case reports and literature review. BMC Musculoskeletal Disorders, 22, 1-8. https://doi.org/10.1186/s12891-021-04728-1

Xia, G., Li, X., Shang, Y., Fu, B., Jiang, F., Liu, H., & Qiao, Y. (2021). Correlation between severity of spinal stenosis and multifidus atrophy in degenerative lumbar spinal stenosis. BMC Musculoskeletal Disorders, 22, 1-7. https://doi.org/10.1186/s12891-021-0

S.

CC (chief complaint): “I feel pain in my ankles, but the right one is more intense.”

HPI:

R.K is a 46-year-old A.A female presenting with a chief complaint of pain in her ankles. She reports that the pain in the right ankle is more intense.  The ankle pain began three days ago when she was playing soccer at the women’s soccer club in her church. She states that she heard a pop sound in her right ankle when playing, which was followed by a sudden intense pain on the right ankle, and she was unable to stand on the right foot. She has, however, been able to walk on the right foot, although it is uncomfortable. R.K also reports having some degree of tenderness and swelling on the right ankle. The ankle pain is aggravated by walking and relieved to some degree by OTC Tylenol, which she takes when the pain aggravates. She rates the pain on the left ankle as 3/10 and the right ankle as 6/10 on the pain scale.

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Current Medications: OTC Tylenol 1 gm for pain.

Vitamin C supplements.

Allergies: Allergic to penicillin- causes rash, hives, and itchy eyes. No known food or seasonal allergies.

PMHx: Last Influenza shot-7 months ago. Last Tetanus- 3 years ago. No history of chronic illnesses. History of an appendectomy at 34 years. History of Tonsillectomy at 7 years.

 Soc Hx:

R.K is a community youth counselor and has a diploma in Counseling. The patient is married. She currently lives with her spouse and three children aged 17, 14, and 8. Her hobbies include traveling and playing football. She is the captain of the women’s soccer club in her church and is the assistant coach for the junior girls’ soccer club. She reports taking wine occasionally but denies smoking tobacco or using illicit substances. She reports having a strict diet and taking about 7 glasses of water a day. The patient states that she has an active lifestyle and takes a morning run for about 40minutes at least 5 days a week. She also plays football on weekends. Her last health exam was 2 years ago.  She states that her support system is her family and sisters.

Fam Hx: Family history of HTN- mother and maternal grandfather. History of breast cancer- paternal grandmother. The elder sister has a history of Asthma. Children are alive and well.

ROS:

GENERAL: Denies elevated body temperature, reduced energy levels, chills, or weight loss/gain.

HEENT:  No history of head trauma, visual changes, hearing loss, ear discharge, nasal discharge/blockage, sneezing, or pain/difficulty swallowing.

SKIN:  Denies color changes, itching, or lesions.

CARDIOVASCULAR:  No history of swelling, chest discomfort, heart palpitations, or dyspnea at rest or exertion.

RESPIRATORY:  No history of chest pain, cough, sputum, or dyspnea.

GASTROINTESTINAL:  Denies appetite changes, nausea/ vomiting, abdominal discomfort, or diarrhea/constipation.

GENITOURINARY:  Denies abnormal PV discharge, dysuria, or urinary frequency/urgency. LMP-3 weeks ago.

NEUROLOGICAL: Negative for dizziness, headache, paralysis, or burning sensations in the extremities.

MUSCULOSKELETAL: Positive for ankle pain and swelling. Limitations in movement. Denies joint stiffness/pain/enlargement.

 HEMATOLOGIC:  No history of bleeding or blood transfusion.

PSYCHIATRIC:  Denies history of mental illnesses.

ENDOCRINOLOGIC: Negative for excessive perspirations, cold/heat intolerance, excessive urination, or acute thirst.

ALLERGIES: Allergic to penicillin.

O.

Physical exam:

VITAL SIGNS: BP- 126/74; HR- 98; RR-20; Temp-98.78 F

                        HT-5’4; WT- 136 pounds.

GENERAL: Neat and well-groomed female in no acute distress. Alert and oriented X4. Speech is clear and goal-directed. Maintains eye contact and exhibits a positive attitude.

CARDIOVASCULAR: Negative for JVD or edema. RRR; S1and S2 audible. No gallop sounds or murmurs heard on auscultations.

RESPIRATORY: Smooth and uniform respirations. Chest clear on auscultation.

MUSCULOSKELETAL: No skin color changes at the ankles.

Left Ankle- No bruising, swelling, or loss of function. Mild tenderness at the anterior aspects of the lateral malleoli. Negative ligamentous laxity with anterior drawer and talar tilt testing.  Decreased total ankle motion of 2 degrees. No bony point tenderness. No difficulty bearing weight.

Right ankle- Bruising present. Moderate tenderness at the maximal points of the anterior (ATFL) aspect of the lateral malleoli on the right ankle. Positive anterior drawer test, negative talar tilt test- moderate joint instability. Some loss of function. Decreased total ankle motion of 7 degrees. Pain with weight-bearing and walking. No bony point tenderness.

Diagnostic results:

X-ray of the right ankle: An X-ray will be required to exclude fractures.

The Ottawa ankle rules indicate that ankle radiographs should be obtained in the event of pain in the malleolar region and any of the following: Pain on the posterior margin of the distal 6 cm or apex of the lateral malleolus; Pain on the posterior margin of the distal 6 cm or apex of the medial malleolus; and Incapacity to bear weight right away after an injury and for four steps during the assessment (Wells et al., 2019).

A.

Differential Diagnoses

Acute Lateral Ankle Sprain

An ankle sprain entails an inversion-type twist of the foot, accompanied by pain and edema. Lateral ankle sprains are the most prevalent injury in physically active populations, primarily among teenagers and young adults (Herzog et al., 2019). Clinical features of ankle sprains include pain, tenderness, swelling, bruising, muscle spasm, and cold foot or paresthesia, which suggest possible neurovascular compromise (Herzog et al., 2019). According to Wells et al. (2019), ankle sprains are categorized as Grade I, II, and III. Grade I have minimal tenderness and swelling, no loss of function, decreased total ankle motion of 5 degrees and below, and swelling of 0.5 cm or below as measured by figure-of-eight testing.

Grade II is characterized by bruising, moderate tenderness, a decreased ROM between 5-10 degrees, moderate swelling of 0.5-2.0cm, and ankle instability (Wells et al., 2019).  Grade III presents with bruising, significant swelling of greater than 2.0 cm, near-total loss of function, ankle instability, extreme point tenderness, and decreased ankle ROM > 10 degrees.

Acute Lateral Ankle Sprain is the presumptive diagnosis based on the positive findings in the right ankle, including bruises, some loss of function tenderness at the anterior aspect of the lateral malleoli, moderate joint instability, reduced ROM of 7 degrees, and pain with weight-bearing and walking. The right ankle symptoms are consistent with a grade II lateral ankle sprain.

Acute Achilles tendon ruptures

Individuals with an Achilles tendon rupture often present with a primary symptom of a sudden snap in the lower calf accompanied by acute, severe pain. According to Egger and Berkowitz (2017), Achilles tendon rupture commonly occurs in healthy, active, young- to middle-aged persons, mostly from 37 to 43.5 years old. Patients often report experiencing a popping or giving way feeling in their posterior heel after pushing off (Egger & Berkowitz, 2017).

Immediate pain occurs but slowly resolves, leaving a person with difficulty with plantar flexion, weight-bearing, or limping. Besides, the person cannot stand their toes on the affected side (Egger & Berkowitz, 2017). Achilles tendon rupture is a differential diagnosis based on findings of ankle pain, popping sensation that occurred during the ankle injury, and difficulties with bearing weight.

Right Ankle Fracture

While lateral ankle sprains comprise 90% of all ankle injuries, whereas an ankle fracture occurs only in 15% of the injuries, ankle fractures occur due to a twisting mechanism sustained from a low-energy injury (Lawson et al., 2018). A fractured ankle presents with severe pain, swelling, ecchymosis, and soft tissue injuries, such as abrasions and lacerations. Other features include loss of function, limited range of motion, compromised neurovascular status, and positive talar tilt and drawer testing (Lawson et al., 2018). A Right Ankle fracture is a differential diagnosis based on pertinent positives of pain, bruising, loss of function, reduced ROM, and positive talar tilt and drawer testing indicating joint instability.

References

Egger, A. C., & Berkowitz, M. J. (2017). Achilles tendon injuries. Current reviews in musculoskeletal medicine, 10(1), 72–80. https://doi.org/10.1007/s12178-017-9386-7

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610. https://doi.org/10.4085/1062-6050-447-17

Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018). Ankle fracture-dislocations: a review. Foot & Ankle Orthopaedics, 3(3), 2473011418765122. https://doi.org/10.1177/2473011418765122

Wells, B., Allen, C., Deyle, G., & Croy, T. (2019). MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES. International journal of sports physical therapy, 14(3), 445–458. https://doi.org/10.26603/ijspt20190445

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:

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.

SAMPLE 2

Name: Ashley Silver

Section: NURS 6512-28

 

Week 8: Assessment of the Musculoskeletal System               

Case Study 2

Patient name: Angel Rodriguez Age: 46           Gender: Female         Ethnicity: Hispanic

Angel Rodriguez is a 46-year-old Hispanic female with complaints of pain in both of her ankles, but more pain and concern about the right ankle. She heard a “pop” when she was playing soccer this past weekend. She has the ability to bear weight, but expresses some discomfort.

SUBJECTIVE DATA: 

Chief Complaint (CC): “I have pain in both my ankles, but more in the right.”

History of Present Illness (HPI): AR is a 46 years-old-female who presents to the clinic for bilateral ankle pain for 3 days. The pain started after she was playing soccer over the weekend and noticed a “pop” sound while playing. She reports the pain as “throbbing, sore, and sharp.” She can bear weight on both ankles but the pain is worse on the right. Her pain is a 6/10 on the severity scale. The pain increases to a 9/10 on the right ankle when ambulating or standing for an extended amount of time. AR has been elevating her ankles on pillows and applied heat and ice packs with no relief. She reports her right ankle is swollen and tender to touch. Currently her pain is 3/10 on the left ankle and 8/10 on the right ankle. 

Current Medications

1. Multivitamin PO daily- name unknown
2. Ibuprofen 800 mg Q6 PRN for pain
3. Tylenol 650 mg Q6 PRN for pain

Allergies: 

No drug, food, seasonal, or animal allergies.

Past Medical History (PMH): No recent hospitalizations were reported. Broke left wrist in May 2015. Osteoporosis at age 45. 

Past Surgical History (PSH): No surgery history.

Sexual/Reproductive History: Last menstrual cycle was 3 weeks ago. Engaged to fiance for 8 months. Fiance is AR’s only sexual partner. 

Personal/Social History: AR’s occupation is a Recreational Therapist at University of Chapel Hill (UNC)- Nash for 5 years. Her fiance and her own their home for the past year. They only share their home with 2 dogs. Rodriguez enjoys playing soccer, reading, shopping, and volunteering at her neighborhood garden. She drinks 2-3 glasses of wine every weekend. She denies smoking tobacco/vapes and illicit street drugs. 

Immunization History: 

• Influenza: 09/13/2022. 46 years old.
• Hep B: 3 dose series completed at 6 months old.
• Hep A: 2 dose series completed at 15 months old.
• Pneumococcal: 4 dose series completed at 15 months old.
• DTaP: 5 dose series completed at 6 months old.
• MMR: 2 dose series completed at 6 months old.
• Varicella: 2 dose series completed at 6 months old.
• Polio: 4 dose series completed at 7 months old.

Significant Family History:

• Mother- age 76, DM2, HTN, HLD,
• Father- age 74- tobacco smoker, HTN, COPD
• Maternal Grand-mother- deceased- age 88- CVA
• Maternal Grand-father- deceased- age 86- MI, tobacco smoker, COPD, HTN
• Paternal Grand-mother- age 87- HTN
• Paternal Grandfather- deceased- age 85- CVA

 

ROS:

• General:Reports feeling fatigued and “extra tired”  from ambulating/bearing weight on her ankles. Reports lack of sleep due to pain. 
• HEENT:
• Head:No headaches reported. Denies dizziness.
• Eyes:Denies problems with eyes.  Denies eye itching, redness, watery or pain. Does wear reading eyeglasses.
• Ears: No history of frequent ear infections. Denies ear surgery history. Denies

ear pain, no swelling or drainage from bilateral ears.  Denies hearing difficulties. Denies ear popping.

• Nose:Denies runny nose, bleeding, or pain. Denies sinus pain.
• Throat:Denies sore throat pain and coughing every few minutes. Denies discolored sputum.
• Cardiovascular:Denies chest pain, tightness, and palpitations
• Respiratory:Denies shortness of breath, wheezing, and cough.
• Musculoskeletal:Denies history of arthritis, limited range of motion. Positive for right ankle swelling, tenderness to touch, pain 9/10. Left ankle full range of motion, no signs of swelling or tenderness, pain 3/10.

 

Objective:

VS: B/P:120/84 T-98.7 F P-80 R-20 SPO2 -100%RA

Weight: 200 lbs.     

Height: 5’ 8’’ ft

General: AAOx4, cooperative, calm,  appropriate to age.  Able to answer all questions 

appropriately. Appears fatigued and grimaces facial expressions.  

HEENT:

Head: Normal size and shape, hair evenly distributed, no masses.

Cardiovascular/ Peripheral Vascular: S1 and S2 heard on auscultation, no murmurs or extra heart sounds. Right ankle with ecchymosis. edema, tender, and warm to touch. Left ankle no

edema or ecchymosis. Bilateral posterior tibial pulses 2+ No thrill. Bilateral dorsalis pedis 2+ pulses no thrill. Capillary refills in digits and phalanges less than 3 seconds.

Respiratory: Clear breath sounds present in all lung fields. No shortness of breath observed. No posterior/anterior masses, bulges, or crepitus felt on palpation. No adventitious breath sounds on auscultation.

Skin: No lesions, bruises, or bumps. Ecchymosis noted on the right ankle.

Muskuloskeletal: Right ankle edema with 4X4 cm ecchymosis on mid-lateral malleolus area with tenderness upon palpation on the lateral side. Active range of motion with pain bilateral ankles and limitation with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsen pain on right. No bony tenderness, deformity, or crepitus.

Diagnostic Results

X-Ray: Internal/external rotation of bilateral ankles

Anterior/posterior drawing test: applied to assess the integrity of ATFL as it prevents anterior translation of the talus under the distal tibia. Ten millimeters of displacement in the injured ankle or more than 3-4 mm of difference in translation compared with the healthy side indicate an ATFL tear.In an ATFL tear, a dimple sign may also be visible in the anterior side of the joint in 50% of cases anterior and posterior cruciate ligament integrity (Halabchi & Hassabi, 2020)

Talar tilt test: evaluates the integrity of the CFL. In this test, the angle between the talar dome and the tibial plafond is measured during forced heel inversion while the tibiotalar joint is in the neutral position. If there is more than 5° of difference with the normal side, the test is considered positive (Halabchi & Hassabi, 2020)

ASSESSMENT

Angel is having persistent pain in bilateral ankles, more in right than left. With her past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments. With Angel working as a Recreational Therapist and playing soccer for leisure, she is up on her feet the majority of the time. Therefore, diagnosing and treating Angel’s chief complaint is crucial. 

Differential Diagnoses:

1. Ankle fracture- Can be a partial or complete break in the bone. Most likely caused by direct or indirect trauma. Patients can complain of being unable to bear weight at all for extended periods of time, swelling, pain, and limited movement. Felt a “pop” or “snap” with injury (Ball et al., 2019). Site appears swollen, deformity, tender to touch, or deformity.
2. Ankle sprain- Acute ankle sprains are one of the most common musculoskeletal injuries and have a particularly high incidence among physically active individuals (Herzog, 2019). They are most common in athletes. In a typical lateral ankle sprain, ecchymosis and tenderness are located over the ATFL and calcaneofibular (CFL) ligaments (Halabchi & Hassabi, 2020).
3. Tenosynovitis (Tendonitis) –Inflammation of the synovial-lined sheath/affected tendon. Patients can complain of pain, especially with movement. The patient can point to the involved tendon. Pain with active movement and some limitation of movement in the affected joint (Ball et al., 2019).
4. Anterior Ankle Impingement-ankle pain that is caused from consistent dorsiflexion (Tausen et al., 2014). The symptoms of anterior ankle impingement are instability, limited range of motion of the ankle, and pain with any movements (Tausen et al., 2014)
5. Osteoarthritis- deterioration of the articular cartilage covering the end of synovial joints. Onset begins at age 40 and further develops with age. The joints may be enlarged and painful range of motion (Ball et al., 2019).

References

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.

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534.

Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610.

Tausen, P., Toy, J., Perez, J. L., Milewski, M. D., & Reach, Jr, J. S. (2014). Anterior ankle impingement: Diagnosis and treatment.

Journal of the American Academy of Orthopaedic Surgeons, 22(5), 333. Retrieved from https://doi-org.ezp.waldenulibrary.org/10.5435/JAAOS-22-05-333.

 

 

 

Response

Hello Ashley! This is an in-depth and compelling post about assessment of the musculoskeletal system. I agree with you that due to the patient’s past medical history of fractured left wrist, there could be an underlying etiology that needs short- term treatment and follow up appointments.   There are various diagnostic tests that can further be performed on this patient. Blood tests can be done to establish whether or not there are underlying infections or conditions that trigger pain in patient (Chisari & Parvizi, 2020). Electromyography (EMG) can also be conducted to study nerves and gauge the electrical impulses produced by the nerve and muscles. EMG can validate nerve compression linked to constricted spinal canal or herniated disks. CT scans or MRI can also be conducted to produce images that may show problems in the blood vessels, nerves, bones, tendons, muscles, and nerves (Guo et al., 2019). On the other hand, this patient should also be given dietary and physical activity education to help in addressing weight and reduction of weight at the ankles.

 

References

Chisari, E., & Parvizi, J. (2020). Accuracy of blood-tests and synovial fluid-tests in the diagnosis of periprosthetic joint infections. Expert Review of Anti-infective Therapy, 18(11), 1135-1142. https://doi.org/10.1080/14787210.2020.1792771

Guo, S., Yan, Y. Y., Lee, S. S. Y., & Tan, T. J. (2019). Accessory ossicles of the foot—an imaging conundrum. Emergency Radiology, 26(4), 465-478. https://doi.org/10.1007/s10140-019-01688-x

Patient Information:  T.J., 15 years old,  African American Male

S.

CC  “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”

HPI:

TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and  localized  around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently  comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .

Reports that Aleve makes it tolerable,  but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.

Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.

Allergies:

No known allergies. Denies food , environmental and latex allergies.

PMHx:

Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.

Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.

SocHx: TJ identifies himself as “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons.  TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies.

Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history.

ROS:

GENERAL:  TJ does not have weight loss, denies fever, chills, weakness or fatigue.

HEENT:  Eyes:  Denies blurred or loss vision. Denies double vision. No  yellowsclerae noted.

 Ears, Nose, Throat:  Reports no hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies  palpitations or edema.

RESPIRATORY:  Denies  shortness of breath, cough or sputum production.

GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood.

GENITOURINARY:  Reports No Burning on urination.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control.

MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee.

HEMATOLOGIC: reports no anemia, bleeding or bruising.

LYMPHATICS: denies enlarged nodes and  history of splenectomy.

PSYCHIATRIC: reports no depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’

Diagnostic tests:

CT scan, MRI, and Xray.

Blood Tests:

CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor)  

Differential Diagnoses

1. Patellofemoral Pain Syndrome .The  main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019).
2. Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019).
3. Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019).
4.  Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019).
5. Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018).

References

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family

                    physician, 99(2), 88–94.

https://pubmed.ncbi.nlm.nih.gov/30633480

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.

ten Thije, J. H., &Frima, A. J. (2019). Patellar dislocation and osteochondral fractures. The Netherlands journal of surgery, 38(5), 150–154.

https://pubmed.ncbi.nlm.nih.gov/3774187

Dains, J. E., Baumann, L. C., &Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Habusta, S., Coffey. R, Ponnarasu S, et al.(2022) Chondromalacia Patella.  

         Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/

Vaishya R, Azizi A, Agarwal A, et al.(2018) Apophysitis of the Tibial Tuberosity  

          doi:10.7759/cureus.780

S.

CC (chief complaint): “Lower back pain.”

HPI: D.T. is a 42-year-old Caucasian male with a chief complaint of lower back pain. He reports that the lower back pain began a month ago. He describes the pain as ‘stabbing’ and often radiates to his left leg. He reports that the pain sometimes causes numbness and weakness in the left leg. The low back pain is constant but worsens with activity, prolonged sitting, and bending. The patient has used OTC analgesic creams and Tylenol, which relieve the pain to some degree but recurs after some hours. He is concerned that the back pain may be long-term since it has already lasted a month. This will significantly interfere with his daily work activities. He rates the pain at 5/10.

Current Medications: OTC Diclofenac cream, applies twice daily. OTC Tylenol 500 mg TDS.

Allergies: Allergic to nuts- causes skin itching, redness, and swelling. No drug allergies.

PMHx: The patient has no history of chronic illnesses or admission. His immunization is not up to date. The last Flu shot was more than three years ago. Last TT- July 2018. He has received both Pfizer COVID-19 shots.

Soc Hx: D.T. is a lab technologist with a degree in Analytical chemistry. He is married and lives with his wife and two children, 15 and 10 years old. His hobbies include playing baseball and fishing. He is the captain of the baseball team in his organization. He denies smoking tobacco but reports taking a few whiskey glasses on weekends to wind up. He also denies any past or current substance use. The patient states that he is generally physically fit since he attends baseball practice 2-3 times a week. In addition, he eats balanced meals with a high composition of proteins and vegetables. He sleeps 5-6 hours a day. D.T. has private health insurance cover that also covers his family and is provided by his employer.

Fam Hx: The patient’s paternal grandfather died from prostate cancer at 82 years. His paternal grandmother died from an RTA at 85 years. His father has a history of high blood pressure. His younger brother has chronic asthma. The patient’s children have no chronic illnesses.

ROS:

GENERAL:  He denies fever, weight changes, or generalized body weakness.

HEENT:  Eyes:  Denies eye pain, excessive tearing, or blurred vision. Ears: Denies changes in hearing or ear pain. Nose: Denies nasal discharge, sneezing, or nose bleeds. Throat: Denies throat pain or hoarseness.  

SKIN:  Negative for skin rash, discoloration, or bruises.

CARDIOVASCULAR:  Negative for palpitations, chest tightness, swelling of lower limbs, or SOB on activity.

RESPIRATORY:  He denies difficulties in breathing, cough, wheezing, or sputum.

GASTROINTESTINAL:  He denies abdominal distress or changes in bowels.

GENITOURINARY:  Denies urinary symptoms of penile discharge. 

NEUROLOGICAL: Reports numbness and weakness in the left leg. Denies dizziness or loss of consciousness.

MUSCULOSKELETAL:  Reports lower back pain and left leg pain. Limited ROM on the left leg because of pain.

HEMATOLOGIC:  He denies bruising or a history of anemia.

LYMPHATICS:  Denies swelling of lymph nodes.

PSYCHIATRIC:  Reports increased stress due to prolonged back pain.

ENDOCRINOLOGIC:  Denies excessive sweating, heat and cold intolerance, excessive thirst or hunger, or increased urination.

ALLERGIES:  Hives when he eats nuts.

O.

Physical exam:

Vital Signs: BP- 122/78; HR- 86; RR-16; Temp-98.4; SPO2- 100%; HT-5’5; WT-167; BMI-27.8

GENERAL: White male patient in his 40s. The patient is calm and in no distress. He is well-groomed and appropriately dressed in casual wear. He exhibits positive facial expressions and body language. His speech is clear and goal-directed, with normal volume and rate.

CARDIOVASCULAR: Regular heart rate and rhythm.S1 and S2 are heard on auscultation. No gallop sounds or murmurs were heard.

RESPIRATORY: Smooth and even respirations. Symmetrical chest wall expansion. Lungs clear bilaterally.

NEUROLOGICAL: CN II – XII are intact; DTRs 2+ on the right leg and 1+ on the left leg. Normal sensation in the right foot; Reduced sensation in the left foot. Muscle strength 5/5 (right lower limb) 3/5 (left lower limb)

MUSCULOSKELETAL: Torso and head are upright. Normal balance when walking and standing, and the arms swing freely at the side. Straight leg raising elicits pain that radiates down the left leg when the left leg is slowly raised above 60°. On raising the right leg, the patient reports pain radiating down the left leg to the foot. ROM 4/5 in the left leg. Back ROM elicited pain with lateral rotation, forward flexion, and spine hyperextension.

Diagnostic results: Spine X-ray: Abnormal spine curve.

A.

Differential Diagnoses

Sciatica: Sciatica is characterized by pain along the sciatic nerve caused by compression of lumbar nerve roots in the lower back. Clinical features of sciatica include unilateral leg pain greater than low back pain; Pain radiating to the foot or toes; Numbness and paresthesia in the same distribution; Straight leg raising test elicits more leg pain; Localized neurology limited to one nerve root (Stynes et al., 2018). This is the most likely diagnosis due to positive symptoms of low back pain radiating to the left leg, numbness on the left foot, straight leg testing producing pain on the left foot, and crossed straight leg raising eliciting pain on the left foot.

Herniated lumbosacral disc: This is characterized by low back pain, limited trunk flexion, and sensory abnormalities at the lumbosacral nerve root distribution (Yu et al., 2022). The patient has low back pain, back pain with forward flexion, and an abnormal spine curve making Herniated lumbosacral disc a differential diagnosis.

Spinal nerve root impingement: This occurs when a spinal nerve root is compressed or irritated. The compression often causes high discomfort, like loss of sensation and weakness. When nerve root impingement occurs, the parts of the body that lie along the nerve’s path are usually the most severely affected (Berry et al., 2019). Compression of a spinal nerve root may have caused low back pain, left leg pain, and weakness. Besides, the abnormal spine curve may have irritated a nerve root.

Lumbar Spondylolisthesis: Lumbar Spondylolisthesisis characterized by intermittent and localized low back pain triggered by flexing and extending the affected segment (Dunn, 2019). The patient has low back pain and back pain with lateral rotation, forward flexion, and spine hyperextension, which are consistent with Spondylolisthesis.

Lower Back Muscle Spasm: Spasm of the lower back muscle is believed to produce secondary low-back pain and tenderness (Urits et al., 2019). This can be the cause of the patient’s lower back pain.

P.  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus, 11(10), e5934. https://doi.org/10.7759/cureus.5934

Dunn, B. (2019). Lumbar spondylolysis and Spondylolisthesis. Journal of the American Academy of PAs, 32(12), 50–51. DOI: 10.1097/01.JAA.0000604892.88852.c6

Stynes, S., Konstantinou, K., Ogollah, R., Hay, E. M., & Dunn, K. M. (2018). Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PloS one, 13(4), e0191852. https://doi.org/10.1371/journal.pone.019185

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., Viswanath, O., Jones, M. R., Sidransky, M. A., Spektor, B., & Kaye, A. D. (2019). Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Current pain and headache reports, 23(3), 23. https://doi.org/10.1007/s11916-019-0757-1

Yu, P., Mao, F., Chen, J., Ma, X., Dai, Y., Liu, G., … & Liu, J. (2022). Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis Research & Therapy, 24(1), 1-18. https://doi.org/10.1186/s13075-022-02894-8

I would agree with your assessment of a herniated disc. A herniated disc is a condition where nucleus pulpous is displaced from the intervertebral space (Dydyk, Ngnitewe, & Mesfin 2023). During this condition it usually happens from a event or trauma that causes the back pain. When a person is experiencing a herniated disc they also may experience a burning or stinging sensation that radiates to the lower extremities.  I would have to disagree with the assessment of ankylosis spondylitis. Early symptoms include  back pain or stiffness in hips and lower back especially in the morning or after inactivity. Ankylosis spondylitis has a genetic link and can run in families (Zhu, He, Cheng, Zhang, Chen, Wang, Oiu, Cao, & Weng, 2019). Does anyone in the patients family have ankylosis spondylitis?  

Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441822/Links to an external site.

Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., Qiu, G., Cao, X., & Weng, X. (2019). Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone research, 7, 22. https://doi.org/10.1038/s41413-019-0057-8

 Thank you for sharing your discussion with us. Your assessment and outlining of the patient’s signs and symptoms indicate an assessment of patellar tendinitis. This is the most likely diagnosis for the patient based on the patient’s history of being an athlete and prior involvement in long jumping, which could have put excessive and repetitive strain on the knee and led to inflammation. Additionally, jumps and movements from basketball could also put additional stress on the knee resulting in pain complaints.

Bursitis is also a condition secondary to tendinitis that has a similar presentation to that of the patient and is associated with overuse and trauma, leading to inflammation (Dains et al., 2019). It, therefore, is an appropriate diagnosis to examine and assess the patient to provide appropriate treatment. It is important to include it as a differential diagnosis as the location of the inflammation can differ. Therefore, treatment can be specifically directed to the inflamed location once a diagnosis is confirmed or ruled out.

The diagnosis that is least likely for the patient from the assessment would be juvenile arthritis (JA). While JA is also an inflammation of the joint that can present as pain, the characteristics of the presenting complaint are not in line with the patient’s presentation. According to Dains et al.(2019), JA can also present with fatigue, low-grade fever, and weight loss. As outlined in your discussion, the patient does not present with these findings.

The diagnosis is further less likely due to the differences in aggravation of symptoms. The patient reports worsening pain with intensive training, and after playing in games while in JA, the pain and stiffness are mostly noted in the night and morning and get better with activity. Swelling at the joint is also a common factor and was not present in this patient. JA is, therefore, the least likely assessment for this patient and the differential diagnosis I would reject.

The patient’s history of sporting activity and athletic training does justify the inclusion of chondromalacia of the patella as a differential diagnosis. According to Habusta et al.(2022), patients with chondromalacia patella do present with pain as the most common presentation and is frequently seen in patients that experience post-traumatic injuries, wear and tear to the hyaline cartilage.

The pain worsens with activities that increase stress on the patellofemoral joint, such as running and jumping, as outlined by the patient. Pain is a common symptom for most musculoskeletal conditions; therefore, it’s important to perform tests and diagnostics to rule out the possible cause of the pain to prevent misdiagnosis. Additionally, including the chondromalacia patella is important as it is sometimes diagnosed via the method of elimination.

References

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

Habusta, S., Coffey, R., Ponnarasu, S., Mabrouk, A., & Griffin, E. (2022). Chondromalacia patella. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/

 

I enjoyed reading your post; however, there could be a few more possible considerations for the patient’s complaint and symptoms presented with the visit, such as peroneal tendon subluxation. The gradual onset pain is usually in the outer part of the ankle or just behind the fibula. Swelling with palpable fluid in the tendon sheath with crepitation (Walt, 2022). The patient may report that the ankle gives away as well as a click feel as the patient moves in the ankle should alert the clinician to the possibility of peroneal tendon subluxation. (Walt, 2022). The peroneal tendon is the primary location for tenderness.

A popping and clicking sound on the outer side of the ankle may be present. Dorsiflexion and eversion of the foot against resistance can be used to test for peroneal tendon subluxation. The ankle may feel as if it is unstable, and sometimes, the patient will be able to demonstrate the subluxation of the tendon. The fleck sign is also an indication of peroneal tendon subluxation. Peroneal tendon subluxation usually occurs more in younger individuals and usually is a sports-related injury, such as in soccer and skiing (Chauhan & Miller, 2017)

During ROM, palpation of the ankle tendons and evaluation of hindfoot biomechanics, such as varus and valgus alignment, should occur with the patient standing.  To assess ankle ligamentous stability ankle drawer test should be done. Laying prone with a knee to 90 degrees flexion and examine for the peroneal tendon. An MRI or ultrasound is beneficial in visualizing this condition of the peroneal tendons and assessing the position of the superior perennial retinaculum and if the tendons are subluxated or not tendon has tares or not (Walt, 2022).  The click, weakness, and pain in the ankle warrant testing and consideration for peroneal tendon subluxation.  This common injury in sports such as soccer is considered a differential diagnosis(Chauhan & Miller, 2017).

References :

Chauhan, Y., & Miller,, J. R. (2017, October). How To Diagnose And Treat Subluxing Peroneal Tendons In The Athlete. Hmpgloballearningnetwork.com. Retrieved April 21, 2023, from https://www.hmpgloballearningnetwork.com/site/podiatry/how-diagnose-and-treat-subluxing-peroneal-tendons-athlete

Walt, J. (2022, May 29). Peroneal tendon syndromes. StatPearls. Retrieved April 21, 2023, from https://www.statpearls.com/ArticleLibrary/viewarticle/27040