NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain

Walden University NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain 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 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain                     

 

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain 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 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain                     

The introduction for the Walden University NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain 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 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain                     

 

After the introduction, move into the main part of the NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain 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 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain                     

 

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 NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain                     

 

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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Discussion: Assessing Musculoskeletal Pain

Thank you for your post, Kasey. Based on the symptoms and ROS you provided, you did a great job at choosing your differential diagnoses. I agree that sciatica is the most likely diagnosis while I would decide to rule out or reject spinal stenosis, arachnoiditis, and spondylolysis. Although I would not reject lumbar disc herniation as a feasible diagnosis, I agree with choosing sciatica as your primary diagnosis because the symptoms reported by your patient such as the sharp, aching pain with a burning sensation that unilaterally radiates to one leg are consistent with this condition; sciatic pain is known to worsen with twisting, bending, and lumbar spine flexion as reported with this patient; and muscle weakness and decreased ROM may occur but not necessarily depending on the cause of the sciatica and where the nerve root compression or pinching occurs along the sciatic nerve (Cleveland Clinic, 2023a; Davis et al., 2022).

I chose to reject spinal stenosis because although the burning, aching pain and lower back pain are consistent with common symptoms of spinal stenosis, the patient denies muscle weakness and there is no mention of numbness, tingling, or cramping which are also common symptoms of spinal stenosis. Also, lumbar spinal stenosis typically affects individuals that are 60 years old and older due to degeneration with age but also younger individuals due to developmental issues; however, developmental issues are not in this patient’s PMH. Additionally, you mentioned in your note that bending, lifting, and twisting made the pain worse, however, with spinal stenosis, flexion of the lower back (bending over) would cause relief of symptoms not worsening of symptoms because the flexion would enlarge the space between the vertebrae and open the spinal column (American Association of Neurological Surgeons, AANS, n.d.; National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIAMS, 2023).

I also decided to reject the diagnosis of arachnoiditis. The condition is typically caused by spinal cord injury, infection leading to spinal cord inflammation, complications as a result of spinal procedures, and/or chronic spinal nerve compression due to other conditions and less commonly caused by other factors such as damage secondary to chemical exposure, genetics, autoimmune issues and conditions such as Guillain-Barré syndrome, and spinal cancer. These risk factors and causes are not in this patient’s history. Arachnoiditis also seems to be more of a chronic disease that progresses slowly over weeks, months, or years while this patient’s symptoms appeared suddenly a month ago with no mention of progression over time. Also, although the burning pain mentioned by the patient is a common symptom, muscle weakness and joint pain are also which the patient denied among other common symptoms and the patient lacks the common neurological symptoms such as headaches and tinnitus (National Institute of Neurological Disorders and Stroke, NINDS, 2023; New York-Presbyterian Hospital, n.d.).

Lastly, I would also reject the diagnosis of spondylolysis because onset of symptoms is insidious not sudden, most individuals with spondylolysis are asymptomatic, and because damage to the pars interarticularis portion of the spine that causes spondylolysis is typically bilateral and not unilateral as it would be in this patient considering that the pain only radiates to the left leg. Also, this condition is typically congenital, occurring in children and adolescents who are genetically predisposed to its development and that also experience repetitive but small traumas to the pars interarticularis related to activities requiring repetitive lumbar hyperextension and rotation such as with sports like football and gymnastics. Lastly, although the pain of spondylolysis can vary between mild to severe, the pain is typically described as dull and aching bot sharp and aching (Cleveland Clinic, 2023b; McDonald et al., 2023).

References

American Association of Neurological Surgeons. (n.d.). Lumbar spinal stenosis. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Lumbar-Spinal-Stenosis

Links to an external site.

Cleveland Clinic. (2023a). Sciatica. https://my.clevelandclinic.org/health/diseases/12792-sciatica

Links to an external site.

Cleveland Clinic. (2023b). Spondylolysis. https://my.clevelandclinic.org/health/diseases/10303-spondylolysis

Links to an external site.

Davis, D., Maini, K., & Vasudevan, A. (2022). Sciatica. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK507908/

Links to an external site.

McDonald, B. T., Hanna, A., & Lucas, J. A. (2023). Spondylolysis. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK513333/

Links to an external site.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2023). Spinal stenosis. National Institutes of Health. https://www.niams.nih.gov/health-topics/spinal-stenosis

Links to an external site.

National Institute of Neurological Disorders and Stroke. (2023). Arachnoiditis. National Institutes of Health. https://www.ninds.nih.gov/health-information/disorders/arachnoiditis

Links to an external site.

New York-Presbyterian Hospital. (n.d.). Arachnoiditis. https://www.nyp.org/ochspine/arachnoiditis#:~:text=Get%20Care-,What%20is%20Arachnoiditis%3F,%2C%20in%20severe%20cases%2C%20paralysis

NURS 6512 Discussion Week 8: Assessing Musculoskeletal Pain

NURS 6512 Discussion Week 8 Assessing Musculoskeletal Pain

Discussion: Assessing Musculoskeletal Pain

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

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.

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.

Episodic/Focused SOAP Note Template

 Case study 1: A 42-year-old male reports pain in his lower back for the past month

Patient Information: CDD_42_M

S.

CC: pain in his lower back

HPI: CDD is a 42-year-old male in the clinic today with c/o lower back pain for over one month. He states the pain radiates to his left leg at times. It has affected his work due to decreased mobility from the pain. Rates the current pain at a 6 out of 10. Has taken Ibuprofen 800mg twice daily for the past few weeks with little to no relief.

Location: Lower back

Onset: One month

Character: Pain that radiates to his left leg.

Associated signs and symptoms: Decreased mobility.

Timing: Accelerates when walking

Exacerbating/ relieving factors: Ibuprofen gives little to no relief

Severity: 6/10 pain scale

Medications:

Lisinopril 10mg PO QD

Ibuprofen 800mg Q6H PRN for pain in back

Allergies:

No known drug allergies

Past Medical History (PMH):

HTN

Past Surgical History (PSH):

None

Sexual/Reproductive History:

Married. Sexually active with wife. Two children, both in college and living away from home

Personal/Social History:

Non-smoker, does not drink, no illicit drug use

Significant Family History:

Mother-hx-HTN, DM

Father-none

Lifestyle:

Electrician by trade, works in a local plant 40 hours a week. Active in the gym, goes several times per week. Married for over 15 years, two sons in college.

Immunization History:

His immunizations are up to date. TDap 2013. Influenza December 1, 2022.

ROS:

General: Denies fatigue, fever, chills, night sweats, and recent weight changes

HEENT: No swelling in the throat. He denies throat pain. No abnormalities noted.

Respiratory: Denies dyspnea, cough

CV: Denies

GI: Denies N/V/D

GU: No change in his urinary pattern.

Neuro: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or

thinking patterns; no twitches or abnormal movements; no history of gait disturbance or

problems with coordination. No falls or seizure history.

Integument/Heme/Lymph: denies

Endocrine: denies

Allergic/Immunologic: No known drug allergies.

O.

Physical Exam:

Vital signs:

Temperature 98.6

 Pulse 78

 RR 18

 BP 112/72

 Weight 182lb Height 5’11

Neurological: awake, alert, oriented to person, place and time

Skin: warm, dry, no breakdown noted

Lungs: clear bilaterally

Cardiovascular: regular rate, S1S2 present

Abdomen: bowel sounds active x4 quadrants, no tenderness noted

Peripheral vascular: No edema, pulses present and strong

HEENT: no abnormalities noted

Musculoskeletal: low back pain that radiates to left leg with mobility limitation. Denies history of arthritis, gout, and musculoskeletal injury

Diagnostic results:

X-Ray lumbar spine

CT Cervical spine/lumbar spine

A.

Differential Diagnoses:

Herniated lumbar disc-A herniated disk refers to a problem with one of the disks between the vertebrae that stack up to make the spine (Jordon et al., 2019). A herniated disk can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg (Jordon et al., 2019). Diagnosis usually includes: CT lumbar spine, X-ray and an MRI.

Sciatica- The sciatic nerve begins at your spinal cord, goes through the hips and buttocks, and then branches down each leg (Ropper & Zafonte, 2018). This nerve is the body’s longest nerve and one of the most important ones, as it has a direct effect on the ability to control the legs/feet (Ropper & Zafonte, 2018). Diagnosis is usually done with a physical exam that will include testing the muscle strength and reflexes to determine if pain is a result from doing so (Ropper & Zafonte, 2018). Also, a CT lumbar spine, X-ray and an MRI will be done.

Muscle strain- Muscle strain is damage to a muscle or its attaching tendons (Orchard & Best, 2020). This can occur when putting extreme pressure on muscles during the course of normal daily activities, with sudden heavy lifting, during sports, or while performing work tasks (Orchard & Best, 2020). A physical exam is done, and possibly an X-ray to rule out other diagnosis. Resting, with the use of NSAIDs is the most common course of treatment (Orchard & Best, 2020).

Spinal Stenosis- Spinal stenosis is a narrowing of the open spaces within the spine, which can put pressure on the spinal cord and the nerves that travel through the spine from the arms and legs (Melancia et al., 2018). Spinal stenosis occurs most often in the lower back and the neck. Spinal stenosis is most commonly caused by wear/tear changes in the spine related to osteoarthritis (Melancia et al., 2018).

Ankylosing Spondylitis- Ankylosing spondylitis is an inflammatory disease that can cause some of the vertebrae in the spine to fuse together (Zhu et al., 2019). X-rays shows changes in joints and bones, though the visible signs of ankylosing spondylitis may not be evident early in the disease (Zhu et al., 2019). 

References

Jordon, J., Konstantinou, K., & O’Dowd, J. (2019). Herniated lumbar disc. BMJ clinical evidence, 2019.

Melancia, J. L., Francisco, A. F., & Antunes, J. L. (2018). Spinal stenosis. Handbook of clinical neurology, 119, 541-549.

Orchard, J., & Best, T. M. (2020). The management of muscle strain injuries: an early return versus the risk of recurrence. Clinical Journal of Sport Medicine, 12(1), 3-5.

Ropper, A. H., & Zafonte, R. D. (2018). Sciatica. New England Journal of Medicine, 372(13), 1240-1248.

Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., … & Weng, X. (2019). Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone research, 7(1), 22. https://doi.org/10.1038/s41413-019-0057-8Links to an external site.

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.

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

1.  

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).

1. 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

Submission and Grading Information

Grading Criteria

To access your rubric:

Week 8 Discussion Rubric

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

To Participate in this Discussion:

Week 8 Discussion

 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

NURS_6512_Week_8_Discussion_Rubric

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		Excellent	Good	Fair	Poor
Main Posting		Points Range: 45 (45%) – 50 (50%) “Answers all parts of the Discussion question(s) with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	Points Range: 40 (40%) – 44 (44%) “Responds to the Discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	Points Range: 35 (35%) – 39 (39%) “Responds to some of the Discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.	Points Range: 0 (0%) – 34 (34%) “Does not respond to the Discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness		Points Range: 10 (10%) – 10 (10%) Posts main post by Day 3.	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) Does not post main post by Day 3.
First Response		Points Range: 17 (17%) – 18 (18%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	Points Range: 15 (15%) – 16 (16%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	Points Range: 13 (13%) – 14 (14%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	Points Range: 0 (0%) – 12 (12%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response		Points Range: 16 (16%) – 17 (17%) “Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	Points Range: 14 (14%) – 15 (15%) “Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	Points Range: 12 (12%) – 13 (13%) “Response is on topic and may have some depth. Responses posted in the Discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	Points Range: 0 (0%) – 11 (11%) “Response may not be on topic and lacks depth. Responses posted in the Discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation		Points Range: 5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days.	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) N/A	Points Range: 0 (0%) – 0 (0%) Does not meet requirements for participation by posting on three different days.
Total Points: 100

Name: NURS_6512_Week_8_Discussion_Rubric

Assessing Musculoskeletal Pain

 

Patient Initials: S.K              Age: 42 years old                             Gender: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “Pain in my lower back for the past one month”

History of Present Illness (HPI): S.K is a 42-year-old Caucasian male patient who reported to the clinic with pain in his lower back that had lasted for about a month. he reports that the pain radiates to his left leg sometimes. The patient reports that the pain is worse when working, and is less disturbing when resting. He has been taking ibuprofen which he claims to provide minimal relief.

Location: lower back

Onset: about a month ago

Character: constant and sharp pain radiating to the left leg

Associated signs and symptoms: None

Timing: When handling strenuous work

Exacerbating/ relieving factors: Any movement worsens the pain. Resting and Ibuprofen provides minimal relief.

Severity: 7/10 on a pain scale

Medications:

• Ibuprofen 800mg PO PRN for the back pain

Allergies:

No known environmental, food, or drug allergies.

 

Past Medical History (PMH):

Denies any history of a serious medical diagnosis

Past Surgical History (PSH):

Denies ever undergoing any surgical procedure in the past.

Sexual/Reproductive History:

Heterosexual

Personal/Social History:

Married with 3 children

Works in a book store downtown.

Has never smoked tobacco or marijuana.

Confirms taking 2 to 3 beers occasionally when with friends.

Immunization History:

Flu shot 17/2/2022

Covid Vaccine #1 2/1/2021 #2 3/1/2021 Moderna

All other immunization up to date

Significant Family History:

Mother- with HTN and DM

Father- with gout and kidney disease

Maternal grandmother- with kidney disease

Maternal grandfather-  died from a stroke

Paternal grandmother- with COPD

Paternal grandfather with CAD, HTN, and COPD.

He has 2 daughters and one son who are all healthy with no significant health complications.

 

Lifestyle:

The patient works in a bookstore downtown. He is happily married to a junior school teacher with 3 children. They live on the outskirts of the city in a 3 bedroom apartment in a safe neighborhood. The means of transport is good, with easily accessible fresh water and healthcare services. He tried as much as possible to eat a healthy diet together with his family. He walks the dog every evening for about a kilometer as a form of exercise. Uses seat belts when in the car, with safety equipment such as a first-aid kit available in their home. He is a strong church member and socializes with his friends mostly over the weekend.

 

Review of Systems:

General: No recent changes in body weight. Complains of pain in his lower back. Denies constipation, fatigue, chills, fever, or generalized body weakness.

HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.

Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.

CV: Denies chest pain, edema, PND, orthopnea, syncope, or palpitations. Dyspnea on exertion

GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.

GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.

MS: Reports lower back pain which sometimes radiates to the left leg. He rates the pain at 7/10 on a pain scale. The severity of the pain however worsens when walking or turning when sleeping. The patient confirms that the pain has lasted for about a month, making it harder to exhibit a full range of movement on the left leg. No numbness, swelling, or redness was reported.

Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.

Neuro: Reports back pain that radiates to the left leg. Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.

Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.

Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.

Allergic/Immunologic: Denies hay fever, urticaria, persistent infections, or HIV exposure.

 

OBJECTIVE DATA

 

Physical Exam:

Vital signs: B/P 140/96, left arm, sitting, regular cuff; P 88 and regular; T 98.9 Orally; RR 18; non-labored; Wt: 215 lbs; Ht: 5’8; BMI 32.69

General: The patient appears healthy, and well oriented in person, place, and time. Seems to be uncomfortable and in moderate pain.

HEENT: External ears normal, with no deformities or lesions. External nose normal with no deformities or lesions. Bilaterally clear canals. Intact tympanic membrane with good movement and no fluid. Grossly intact bilateral hearing. Normal nasal mucosa, septum and turbinates. Complete and good hygienic dentation.

Neck: Supple with no masses. Trachea midline, No thyroid nodules, tenderness, or masses.

Chest/Lungs: Bilaterally clear to auscultation. Tactile fremitus normal. No signs of egophony. Normal respiratory effort displayed with no use of accessory muscles.

Heart/Peripheral Vascular: S1, and S2, note. Normal cardiac rhythm with no murmur, gallop, or rubs.

ABD: Suprapubic surgical scar, obese, non-tender, soft, and non-distended abdomen with no masses.

Genital/Rectal: The patient did not consent to this examination.

Musculoskeletal: Low back pain noted, radiating to the left lower leg. No evidence of trauma affecting the area was noted. Tenderness increases with extension, flexion, and twisting. Limited ROM in the left leg.

Neuro: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes.

 

Diagnostics/Lab Tests and Results:

CBC – To evaluate for spinal infections

CSF analysis- For suspected spinal infection or inflammatory etiologies

X-ray of the spine- for flexion-extension views to identify spondylolisthesis and spinal instability.

MRI of the spine- to assess for suspected myelopathy or radiculopathy.

Electromyography (EMG)- to confirm compressions caused by spinal stenosis or herniated disks (Urits et al., 2019).

 

Assessment:

Differential Diagnosis (DDx):

• Sciatica: This condition is characterized by pain that normally radiates along the sciatic nerve path, which branches from the patient’s lower back through to the buttocks and hip, and down to each leg (Kim et al., 2018). However, sciatica normally affects one side of the body. The patient in the provided case study presents with lower back pain that radiates to the left leg, which is a great indication of sciatica as the primary diagnosis.
• Lumbar disc herniation: LDH is characterized by lower back pain and is common among adults between the age of 35 and 50 years. It normally results from changes in the structure of the lower lumbar spinal disk between the 4^th and 5^th vertebrae and between the 5^th lumbar vertebra and the 1^st sacral vertebra (Benzakour et al, 2019). Most patients normally present with symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness at the lumbosacral nerve roots distribution. The patient in the provided case study displayed lower back pain, however, an MRI of the spinal column is needed to confirm this diagnosis.
• Lumbar spinal stenosis: LSS is associated with narrowing of the spinal canal located in the lower back resulting in pain. Stenosis causes pressure on the patient’s spinal cord or nerves connecting the spinal column and the muscles (Deer et al., 2019). As such patients will present with lower back pain just like the one in the provided case study. However physical examination is required to assess for the presence of loss of sensation, abnormal reflexes, and weakness to confirm this diagnosis.
• Lumbar muscle strain: LMS is described as an injury to the lower back characterized by mild to moderate lower back pain. The injury can lead to damage to the muscle or tendons causing spasms and soreness (Urits et al., 2019). An x-ray is however needed to confirm the impact of the injury on the tendon or muscle to confirm the diagnosis
• Ankylosing spondylitis: This is an inflammatory disorder, that can lead to some of the spinal bones fusing over time. It is characterized by pain in the joints and the back (Ogdie et al., 2019). Symptoms normally appear early in life, including reduced flexion of the spine. The patient only presented with back pain which radiates to the left leg with no joint pain or reduced flexion of the spine.

 

Primary Diagnoses:

1.) Sciatica

PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]

References

Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International orthopedics, 43(4), 841-851. https://doi.org/10.1007/s00264-018-4247-6

Deer, T. R., Grider, J. S., Pope, J. E., Falowski, S., Lamer, T. J., Calodney, A., … & Mekhail, N. (2019). The MIST guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Practice, 19(3), 250-274. https://doi.org/10.1111/papr.12744

Kim, J. H., van Rijn, R. M., van Tulder, M. W., Koes, B. W., de Boer, M. R., Ginai, A. Z., … & Verhagen, A. P. (2018). Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review. Chiropractic & manual therapies, 26(1), 1-14. https://doi.org/10.1186/s12998-018-0207-x

Ogdie, A., Benjamin Nowell, W., Reynolds, R., Gavigan, K., Venkatachalam, S., de la Cruz, M., … & Park, Y. (2019). Real-world patient experience on the path to diagnosis of ankylosing spondylitis. Rheumatology and Therapy, 6(2), 255-267. https://doi.org/10.1007/s40744-019-0153-7

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., … & Kaye, A. D. (2019). Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Current pain and headache reports, 23(3), 1-10. https://doi.org/10.1007/s11916-019-0757-1

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

Thank you for your well-thought-out explanation of the possible and differential diagnosis of the cause of back pain that radiates to the back of the 42-year-old patient in this case study. Many conditions can present with the patient’s symptoms, but the goal of a differential diagnosis is to get the most accurate guessing diagnosis that will help with making the right diagnosis out of possible options. I will have to accept the differential diagnosis of sciatica instead of mechanical back pain for some reasons found in the patient’s presenting signs, characteristics of the pain, and the pain location. First, the patient says the pain radiates to his left leg occasionally, which means unilateral radiation. Sciatic nerve pain (sciatica) is a pain or discomforting sensation caused by the compression or irritation of the sciatic nerve, the largest and longest in the human body, that extends from the lower back through the hips and buttocks down each leg and the most common cause of sciatic nerve pain is a herniated or bulging disc in the spine, which puts pressure on the nerve (Aguilar-Shea et al.,2022). Since sciatica pain is known to originate in the lumbar region and radiate down one leg, the patient’s description of pain radiating to the left leg fits the well-documented pattern of symptoms associated with sciatica, making sciatica most likely a differential diagnosis for the 42 years old patient. Finally, the persistent nature of the pain, its localization to one leg, and its protracted duration all point toward sciatic nerve injury as a likely cause because, during an assessment, “pain that is reproduced during hip flexion and experienced primarily in the back is likely due to a lumbar disc herniation felt in the leg due to lateralizing compression of a peripheral nerve” (Davis et al., 2022. para. 7). The description above fits in the patient’s presentation and description of back pain hence the choice to accept the differential diagnosis of sciatica over mechanical nerve strain diagnosis. Thank you again for sharing.

References

Aguilar-Shea, A. L., Gallardo-Mayo, C., Sanz-González, R., & Paredes, I (2022). Sciatica. Management for family physicians. Journal of Family Medicine and Primary Care 11(8): p 4174-4179, August 2022. | DOI: 10.4103/jfmpc.jfmpc_1061_21 

Davis, D., Maini, K., & Vasudevan, A. (2022) Sciatica. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.: https://www.ncbi.nlm.nih.gov/books/NBK507908/.