NURS 6512 Assessing Musculoskeletal Pain

Sample Answer for NURS 6512 Assessing Musculoskeletal Pain Included After Question

BY DAY 3 OF WEEK 8

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

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

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.

A Sample Answer For the Assignment: NURS 6512 Assessing Musculoskeletal Pain

Title: NURS 6512 Assessing Musculoskeletal Pain

Episodic/Focused SOAP Note Template

Patient Information:

PH, 15-years-old, Male, Filipino

S.

CC: Knee pain

HPI: PH, 15-year-old Filipino male presents with bilateral knee pain for over a week. PH describes the pain as dull with occasional “clicking” or “catching” in one or both knees. PH reports that the pain started a couple weeks after basketball season started this year. PH stated he had pain similar to this last spring during track when he started competing in long jump. PH reports that it hurts more after practice than it does after a game stating, “coach has me doing extra running and jumping drills, he’s really hard on us.”

Location: Knees, under patella

Onset: A week ago

Character: dull

Associated signs and symptoms: occasional clicking of one/both knees, “catching” sensation

Timing: “after practice”

Exacerbating/relieving factors: track and basketball practice make it worse; ibuprofen and ice/heat help make it ache less

Severity: 6/10 pain scale

Current Medications:

Ibuprofen 200mg PO after practice

Multivitamin (OTC) PO daily

Allergies:

Denies food or environmental allergies.

Adhesives- rash at site

Tylenol- nausea

PMHx:

Current and up to date on all immunizations, influenza vaccine received this season, but did not receive COVID-19 vaccines.

Tonsillectomy and adenoidectomy- 2012

Fractured Ulna- 2020 from basketball injury

Reports several sprained ankles from basketball and track.

Denies concussions or previous knee injuries.

Soc Hx:

Freshman in high school, track and field athlete (long jumper), and JV basketball player (small forward). Lives with parents and younger brother. Denies tobacco, alcohol, or illicit drug use. Denies sexual activity, advises he has a girlfriend. PH reports always wearing a seatbelt. PH plays golf with friends outside of school and enjoys playing Xbox on weekends with his friends from the track team. PH reports he has several friends that support him at school and family that encourage him in academics and sports. PH advises he feels a lot of pressure from basketball coach to “be the best”.

NURS 6512 Assessing Musculoskeletal Pain
NURS 6512 Assessing Musculoskeletal Pain

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Fam Hx:

Mother: HTN, Hyperlipidemia, Depression

Father: DM2, HTN, Hyperlipidemia

Brother: No known history.

MGM: HTN

MGF: No information available

PGM: HTN, Hyperlipidemia

PGF: Deceased at 54 from MI

ROS:

Example of Complete ROS:

GENERAL:  No weight loss, fever, or chills. Reports general weakness after practices and games. Reports academic and athletic success.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears: No hearing loss or tinnitus. Nose: No sneezing, congestion, loss of smell, runny nose, or epistaxis. Throat: No sore throat, erythema, or lesions.

SKIN:  No rash or itching. Reports having occasional acne on forehead. Reports underarm hair.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough, or sputum. Reports infrequent, unproductive cough after running sprints during basketball practice.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Last BM 1/16/23 no melena, constipation, or loose stool.

GENITOURINARY:  Denies burning or pain with urination, frequency, or nocturia.  

NEUROLOGICAL:  No dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports headaches after studying all night for tests.

MUSCULOSKELETAL:  Reports dull bilateral knee pain. Ankle pain previously with sprain—currently resolved. Denies immobility.

HEMATOLOGIC:  No anemia or bleeding. Identifies bruise on right shin from exercise injury.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety. Reports feeling pressure from basketball coach to “be the best.” Reports a supportive social and family group.

ENDOCRINOLOGIC:  No reports of cold or heat intolerance. No polyuria or polydipsia. Reports sweating more than last year and must apply deodorant again before practice.

ALLERGIES:  No history of asthma, environmental or food allergies. Acetaminophen- nausea. Adhesives (tape)- rash at site.

O.

Physical exam:

VS: BP 115/64, HR 80, RR 16, O2 98%, 36.8 C, 65 inches, 54.4kg, BMI 20

GENERAL: PH is dressed appropriately and well groomed. PH able to maintain erect sitting position for examination and appropriate historian for current chief complaint, requires assistance from mother on allergies and past medical history.

NEUROLOGICAL: Alert and oriented. Cranial nerves intact. Upper and Lower extremity strength equal bilaterally. Reflexes 2+.

SKIN: Acne present near hairline of forehead. No scaring, lesions, rashes, or moles present. Appropriate for ethnicity. Hair pattern presenting at underarms. Nails are short without brittle texture, pitting, or ridging.

HEENT: Head- symmetric. Ears: symmetric bilateral, negative tenderness and discharge, eardrum pearly grey, and no erythema. Eye: PERRLA 3/2 brisk equal response, negative nystagmus, white sclera, brown iris, and eye lids equal. 20/20 vision using Snellen chart. Nose: nares equal, no erythema in nasal cavity, no postnasal drip, patent turbinates, no polyps, PH can identify smells presented.

NECK: No palpable/enlarged lymph nodes. Trachea midline. Appropriate ROM bilateral.

RESPIRATORY: No SOB. Breath sounds clear a/p in all lobes. No adventitious breath sounds. Chest expansion symmetric with inhalation and exhalation. Work of breath appropriate for examination, no dyspnea noted.

CARDIOVASCULAR: S1, S2 heard, rate and rhythm regular. No carotid, renal, or aortic bruits identified. Extremities color appropriate for ethnicity and warm. Radial and dorsalis pedis pulses 2+.

ABDOMEN: Symmetric, normoactive bowel sounds all quadrants, no palpable masses, no tenderness or guarding.

GENITALIA: Minimal pubic hair noted, uncircumcised, no tenderness at penis or scrotum, no masses identified.

MUSCULOSKELETAL: ROM of all extremities appropriate, stiffness and guarding of knees occurs when transitioning from sitting to standing. Clicking noise noted when patient stood. No joint swelling or redness. No kyphosis, lordosis, or scoliosis. Grade 5 muscle strength. Obvious discomfort noted with initial transition from sitting to standing and stepping up on step. Q angle 14°.

Diagnostic results:

Ultrasound- This a non-invasive test that can provide dynamic structure images of the knee to confirm or eliminate possible diagnoses (Santana & Sherman, 2020).

MRI- Can be used to identify patellar tendon abnormalities as well as osseous and soft tissue injuries (Nacey et al., 2017). Ultrasounds used in conjunction with MRI’s can both eliminate diagnoses, but also confirm.

Erythrocyte Sedimentation Rate (ESR)- this lab test measures the sedimentation rate of red blood cells to detect inflammation. This can be used to diagnose juvenile arthritis (JA) (Daines et al., 2019).

CBC- this lab test would be used to identify an increase in WBC which can identify inflammation as well but is not diagnostic (Dains et al., 2019).

X-ray- a four view radiograph image (a/p, lateral, and skyline views are useful to eliminate JA as well as determine if there are osseous abnormalities (Santana & Sherman, 2020).

A.

Differential Diagnoses

  1. Patellar Tendinitis – According to Santana & Sherman (2020), patellar tendinitis (also

known as “jumper’s knee”) is a result of overuse and stress on the patellar tendon and quadriceps. History and signs of patellar tendinitis include overuse of the jumping or running motion and symptoms include dull pain at the patella and clicking can accompany the pain (Dains et al., 2019). Due to PH recent overuse of patellar tendons and quadriceps with long jumping in the spring and currently overworked during basketball season has caused the patient to present with dull knee pain and clicking and catching of knees making patellar tendinitis most likely. Ruling out other diseases by utilizing US, MRI, X-ray, CBC, and ESR since there is no definitive test to confirm patellar tendinitis (Santana & Sherman, 2020).

  1. Chondromalacia of the Patella – Dains et al. (2019) is caused by trauma to the patella, misalignment, or anatomical abnormalities. Four-view radiography should be used to rule out JA. Chondromalacia pain occurs with activity rather a result of activity making it less likely to be the diagnosis since PH pain occurs after strenuous activity and there is no pain on patella palpitation. Habusta & Griffin (2020) also state that this is more prominent is young female adolescents, not males.
  2. Juvenile Arthritis – Dains et al. (2019) describe history of JA as joint stiffness and pain, fatigue, weight loss, and refusal to walk with symptoms being limited ROM, bilateral joint pain, rash, fever, and joint swelling. PH presents with painful knees bilaterally, but does not present with fever, joint swelling, or rash. A CBC would demonstrate increased WBC, ESR would be positive for antinuclear antibodies and rheumatoid factor. Most JA diagnosis occurs before 16-years-old, it does not appear this patient is likely to have JA, but should not be eliminated until diagnostic tests and labs can be completes.
  3. Bursitis – Bursitis is caused by chronic overuse resulting in local tenderness and swelling, limited joint movement, and muscle weakness (Dains et al., 2019). US and MRI testing combined can be used to identify bursitis and the depth and severity of inflammation (Williams & Sternard, 2019). PH’s injury is acute and is not from chronic overuse; however should not be eliminated until an US and MRI can rule out bursitis. This is not a primary diagnosis due to lack of symptoms mirroring what the patient is presenting with.
  4. Patellar Maltracking – “Patellar maltracking occurs as a result of an imbalance in the dynamic relationship between the patella and trochlea. This is often secondary to an underlying structural abnormality,” (Jibri et al., 2019). Imaging used to diagnose maltracking includes MRI to note subtle changes in dislocation of the patella; however, without any documented history of dislocation it makes it difficult to diagnose.

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

When assessing a patient getting a full history is essential to assist in diagnosing a patient or ordering the most appropriate tests and imaging to rule out possible diagnoses. This patient case study only described the pain and stated his age, current activities were up to us to fill in which guides the differential diagnosis. If this patient did not demonstrate overuse of the patella, it would make some differential diagnoses unlikely. Based on the information provided and filled in determines the overall diagnostic tests and diagnosis. Listed in the subjective and objective data is both information provided and information needed to create possible differential diagnoses.

References

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

Habusta, S. F., & Griffin, E. E. (2020). Chondromalacia Patella. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459195/

Links to an external site.

Jibri, Z., Jamieson, P., Rakhra, K. S., Sampaio, M. L., & Dervin, G. (2019). Patellar maltracking: an update on the diagnosis and treatment strategies. Insights into imaging10(1), 65. https://doi.org/10.1186/s13244-019-0755-1

Nacey, N. C., Geeslin, M. G., Miller, G. W., & Pierce, J. L. (2017). Magnetic resonance imaging of the knee: An overview and update of conventional and state of the art imaging. Journal of magnetic resonance imaging : JMRI45(5), 1257–1275. https://doi.org/10.1002/jmri.25620

Santana, J. A., & Sherman, A. l. (2020). Jumpers Knee. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532969/

‌ Williams, C. H., & Sternard, B. T. (2019). Bursitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513340/

A Sample Answer 2 For the Assignment: NURS 6512 Assessing Musculoskeletal Pain

Title: NURS 6512 Assessing Musculoskeletal Pain

I enjoyed reading your post! In your episodic/SOAP note, you gave detailed information and painted a “realistic picture” of the patient. Recently, a medical doctor told me, “our bodies give us warning signs when it’s in distress. When the body is in distress, it tries to repair the issue. If the body does not repair the issue on its own, it’s up to healthcare professionals to figure out the etiology and treatment.” 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.

Case Study 3

In your assigned case study, the patient, PH,  is a 15-year-old Filipino boy with complaints of bilateral knee pain for over a week. He describes the pain as dull intermittent “clicking” or “catching in one or both knees. PH reports that the pain started a couple weeks after basketball season started this year. PH stated he had pain similar to this last spring during track when he started competing in long jump. PH reports that it hurts more after practice than it does after a game stating, “coach has me doing extra running and jumping drills, he’s really hard on us.” He has a history of an ulnar fracture and multiple sprained ankles from basketball and track, but no previous knee injuries.

Patellar injury differential diagnosis- Patellar Tendonitis

Your differential diagnosis were Patellar Tendonitis, Chondromalacia of the Patella, Juvenile Arthritis, Bursitis, and Patellar Maltracking. Agreeably so, I believe Patellar Tendonitis is the primary diagnosis. Your description of the condition is best with PH reported signs and symptoms. Chronic inflammation, such as patellar tendonitis, leads to a weakened tendon and can increase the likelihood of tendon rupture. Certain medical conditions can lead to an overall weakened tendon and can also predispose an individual to tendon rupture such as patellar degeneration, overuse injury, and previous injury (Hsu & Siwiec, 20121). 

Patellar injury differential diagnosis- Chondromalacia of the Patella 

Chondromalacia of the Patella occurs with activity rather than a result of the activity. Chondromalacia patella (CMP) is when the posterior articular surface of the patella starts losing its density when in a healthy state and turns to be softer with subsequent tearing, fissuring, and erosion of the hyaline cartilage (Habusta et al., 2021). You stated that the condition is found more in women than men. According to (Habusta et al., 2021), CMP is more common in women than men and this is attributed to increased Q angles in women. Therefore, this will be a least likely primary diagnosis for PH since he is male gender. 

Patellar injury differential diagnosis- Juvenile Arthritis

Juvenile Arthritis (JA), isn’t a specific condition. It is a broad term that describes numerous rheumatoid conditions in children. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms (Martini et al., 2022). Agreeably so, the majority of JA conditions are diagnosed at age 16 and older. One with JA can exhibit a fever, joint inflammation, swelling, pain and tenderness, but some types of JA have few or no joint symptoms or only affect the skin and internal organs (Arthritis Foundation, 2021). As you stated, it is least likely that PH has JA, but should not be completely eliminated until ruled out by further testing. 

Patellar injury differential diagnosis- Bursitis

Bursitis does require treatment by a physician. The olecranon and prepatellar bursae are the most often involved sites, as their superficial location exposes them to injury. Among patients with bursitis, 80% are males aged 40 to 80 years who constitute the population most exposed to trauma and micro trauma during manual labor or recreational activities (Lormeau et al., 2019). PH unlikely has Bursitis due to the big gap in age and presenting symptoms. Therefore, I would eliminate this differential diagnosis. 

Patellar injury differential diagnosis- Patellar Maltracking

Your last differential diagnosis was Patellar Maltracking. Patellar Maltracking refers to the dynamic relationship between the patella and trochlea during knee motion. Patellar maltracking occurs as a result of imbalance of this relationship often secondary to anatomic morphologic abnormality. Usually, young individuals, particularly women, suffer the consequences of this disorder (Jibri et al., 2019). 

References

Arthritis Foundation. (2023). Juvenile Arthritis (JA). Retrieved January 17, 2023 https://www.arthritis.org/diseases/juvenile-arthritis

Habusta, S. F., Coffey, R., Ponnarasu, S., & Griffin, E. E. (2021). Chondromalacia patella. In StatPearls [Internet]. StatPearls Publishing.

Hsu, H., & Siwiec, R. M. (2021). Patellar tendon rupture. In StatPearls [Internet]. StatPearls Publishing.

Jibri, Z., Jamieson, P., Rakhra, K. S., Sampaio, M. L., & Dervin, G. (2019). Patellar maltracking: an update on the diagnosis and treatment strategies. Insights into imaging10(1), 1-11.

Lormeau, C., Cormier, G., Sigaux, J., Arvieux, C., & Semerano, L. (2019). Management of septic bursitis. Joint Bone Spine86(5), 583-588.Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers8(1), 1-18.

Martini, A., Lovell, D. J., Albani, S., Brunner, H. I., Hyrich, K. L., Thompson, S. D., & Ruperto, N. (2022). Juvenile idiopathic arthritis. Nature Reviews Disease Primers8(1), 1-18.

A Sample Answer 3 For the Assignment: NURS 6512 Assessing Musculoskeletal Pain

Title: NURS 6512 Assessing Musculoskeletal Pain

  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/

Case Study #1-

A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg.

Patient Information:

Initials: T.B.  Age: 42  Sex: Male  Race: Caucasian

S.

CC: “Back pain”

HPI: T.B. is a 42-year-old Caucasian male that presents today with back pain. States that the pain is in his left lower back and started approximately one month ago. He describes the pain as a dull ache that sometimes radiates to his left leg. Reports increased fatigue because he is unable to sleep well at night due to the discomfort, however no additional associated symptoms. States that the pain is consistent throughout the day regardless of resting or being active. He has tried to manage the pain with heating and cooling pads and Advil two times per day with minimal relief. He rates the overall severity of the pain a 7/10.

Current Medications:

Metoprolol 25mg Q day- prescribed for hypertension, started 3 years ago.

Advil- 400 mg BID- OTC for pain management, using every day for past month

Allergies:

Penicillin- rash/ hives in childhood

Seasonal allergies

Peanuts- anaphylactic reaction

PMHx:

Hypertension- diagnosed 3 years ago, managed with medication

No prior hospitalizations or surgeries

Received all childhood vaccinations; Last tetanus vaccine 4 years ago. Received seasonal influenza vaccine and complete COVID-19 series with one booster.


Soc Hx:

Has his Bachelors in Business Administration in Finance and Accounting and works as a Certified Public Accountant (CPA) at Bradson & Willard Law Firm. He is an only child and his parents live in a different state. He lives in an apartment by himself downtown close to his job and primarily uses public transportation, however, owns his own vehicle which is reliable. He has health insurance and benefits through his employer. He has never been married, is not currently dating, and has no children. He likes to golf on the weekends,  ride his bike on local trails, and go to the gym every day. Denies using tobacco or any illegal substances. Reports that he drinks 1-2 beers every night and 3-4 when he goes out with friends.

Fam Hx:

No siblings.

Mother- Anemia; Age 68

Father- Hypertension, high cholesterol; Age 70

Paternal grandmother- Osteoporosis, hypertension; Passed away at age 83 due to a stroke.

Paternal grandfather- Hypertension, high cholesterol, congestive heart failure; Passed away at age 85 due to a heart attack.

Maternal grandmother- Anxiety, Celiac’s disease- age 90

Maternal grandfather- Chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), atrial fibrillation- Passed away at age 88 due to pneumonia.

ROS:

GENERAL: + fatigue; No reported weight loss, fever, chills, or weakness.

HEENT: Denies headaches or dizziness. Denies visual loss, blurred or double vison; Does not wear glasses or contacts. Denies changes in hearing or recent ear infections. Denies changes in sense of smell, congestion, or runny nose. Denies sore throat or difficult swallowing.

SKIN:  No rashes, redness, or areas or irritation.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath or cough.

GASTROINTESTINAL:  Denies changes in bowel habits including nausea, vomiting, constipation or diarrhea. No abdominal pain or blood in stools.

GENITOURINARY:  Denies changes in urination or hematuria.

NEUROLOGICAL:  Reports intermittent paresthesia to left leg. Denies issues with balance or coordination. No change in bowel or bladder control.

MUSCULOSKELETAL: + left lower back pain that radiates to left leg, denies muscle weakness. Denies any history or recent falls, fractures, or trauma to the back.

HEMATOLOGIC:  No history of anemia, denies any abnormal bruising.

LYMPHATICS: Denies enlarged nodes.

PSYCHIATRIC: No past psychiatric history including depression or anxiety.

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

ALLERGIES:  Penicillin, peanuts and seasonal allergies.

O.

Physical exam:

Vital signs: BP: 135/82, HR 85, RR-18, O2- 99% on RA, T-36.7

Height- 6’1”, Weight 285 lbs. (129 kg), BMI- 37.6

General: Patient is calm, alert and oriented. Sitting up on examination table and answering questions appropriately. Has good hygiene and is wearing the appropriate clothing for the cold weather. Does not appear distressed but occasionally grimaces with shifting movements.

Cardiovascular: S1 and S2 present, no murmurs, gallops, or friction rubs present on auscultation.  No JVD. No edema or peripheral vascular disease noted. +2 bilateral radial and pedal pulses. Capillary refill less than 3 seconds in fingers and toes.

Respiratory: Breathing is quiet and unlabored. Breath sounds are present in all areas without adventitious noises.

Musculoskeletal: Expected ROM in extension and flexion of the spine. Reduced lateral bending and spinal rotation to the left. Reports increased pain twisting and bending. Expected ROM in flexion, extension, abduction and adduction of hips.

Neurological: Alert and oriented. Denies headache, dizziness, or coordination issues. Sensation intact in all extremities. Reports intermittent paresthesia in left lower extremity.

Diagnostic results: Computed tomography (CT), magnetic resonance imaging (MRI), or x-ray to identify any abnormalities. Bloodwork such as a complete blood count (CBC) , erythrocyte sedimentation rate (ESR), and c-reactive protein can be drawn to look for infection and inflammation.

A.

Differential Diagnoses

Mechanical back strain- typically presents as lower back pain that can radiate to legs with intermittent spasms that impacts the spine, intervertebral discs, or surrounding soft tissues (El-Sayed & Callahan, 2023). It can be caused by physical or non-physical activity, however lifting is the most common cause (El-Sayed & Callahan, 2023). Patient reports that he goes to the gym every day and therefore a mechanical back strain is likely.

Sciatica- is directly related to the sciatic nerve that typical presents as unilateral pain in the lumbar spine with intermittent paresthesia (Davis et al., 2022). Sciatica pain is typically amplified with flexion of the lumbar spine as well as twisting or bending (Davis et al., 2022). Sciatica can be caused by a number of conditions and therefore further diagnostic workup would be required.

Lumbar disc herniation- can cause lower back pain that worsens with certain movements and sensory abnormalities that originate from the lumbosacral region (Al Qaraghili & De-Jesus, 2023). Further diagnostic workup should be acquired to determine diagnosis.

References

Al Qaraghli, M., & De Jesus, O. (2023). Lumbar disc herniation. Journal of orthopaedic science :official journal of the Japanese Orthopaedic Association, 18(2), 220–229. https://doi.org/10.1007/s00776-012-0354-1

Links to an external site.

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

Links to an external site.

El-Sayed, M., & Callahan, A. L. (2023). Mechanical back strain. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542314/

Thank you for the detailed information about your patient in your SOAP note. I enjoy reading it.

Ankle pain and ankle injuries are very common. Ankle pain is any Pain or discomfort affecting any part of the ankle. Ankle pain can happen for many reasons. The most common causes include injury, arthritis, and normal wear and tear. Depending on the cause, there is a feeling of Pain or stiffness anywhere around the ankle. The ankle may also swell, and you cannot put any weight on it. Usually, ankle pain gets better with rest, ice, and over-the-counter pain medications. People who are more likely to have ankle pain are people over age 65, play sports or do activities that involve jumping, side-to-side movements, or quick changes in direction, and are overweight (Cleve Land Clinic, 2023). Depending on the diagnosis, the doctor may suggest a brace, walking boot, splint, cast, and crutches. They also might recommend physical therapy (PT), which teaches exercises to strengthen the muscles and ligaments around the ankle. PT also can improve flexibility and balance. More severe injuries may require surgery (Waryasz, 2022). Acute ankle pain can occur when any of those structures are injured. The most common ankle injuries among active, athletic people like this patient are fractures, a broken bone, and sprained ankle, strain, and Tendon injuries. I agree with the diagnostic test you listed because Physical exams and imaging tests, including an X-ray, ultrasound, or MRI, will help the provider to understand what is happening to the patient. 

Based on the patient’s HPI and available data, I agree that the primary diagnosis will be the Achilles tendon rupture, as the sprain and ankle fx do not make a pop sound. Achilles tendon rupture is an injury that affects the back of the lower leg. It mainly occurs in people playing recreational sports, but it can happen to anyone. The Achilles tendon is a strong fibrous cord that connects the muscles in the back of the calf to the heel bone. The Achilles tendon can tear (rupture) completely or partially if it is overstretched. If the Achilles tendon ruptures, you might hear a pop, followed by an immediate sharp pain in the back of the ankle and lower leg that is likely to affect a person’s ability to walk properly, while a sprain involves a tear or other damage to ligaments or connective tissue that attaches bone to bone. An ankle fracture is a break in one of the three main bones at the ankle joint. These include the talus, fibula, and tibia. Therefore, the sprain and ankle fracture will not be my primary diagnosis.

References

Cleve Land Clinic. (2023). Ankle Pain. https://my.clevelandclinic.org/health/symptoms/15295-ankle-pain#:~:text=The%20most%20common%20causes%20include,%2Dthe%2Dcounter%20pain%20medications.

Waryasz, G. (2022). Ankle Injuries – When to See a Doctor. https://www.massgeneralbrigham.org/en/about/newsroom/articles/ankle-injuries-medical-attention#:~:text=Depending%20on%20the%20diagnosis%2C%20your,and%20ligaments%20around%20your%20ankle. 

This is an informative post. Patient assessment was important in establishing the reasons for pain and other possible underlying conditions. Another differential diagnosis I would suggest is lumbosacral muscle strains/sprains. This is a condition associated with traumatic episodes. The pain increases with movement and alleviates with a limited range of motion and rest. The development of low back pain can be associated with the sensitization of nerve endings by releasing chemical mediators, in-growth of neurovascular into the degenerated disk, and alteration in the biomechanical properties of the disk structure (Ma et al., 2019). The development of an effective management plan in this case needs a refined subjective assessment to foster streamlining of physical examination. Interviewing the patient about the behavior of the symptoms and taking the history of the condition is vital in establishing the clinical rationale for the causal factors and causes of symptoms. The management plans frequent observation for regularity or reduction of pain, a sporadic repeat of CT scans and X-rays, and referring the patient to rehabilitation or a physical therapist for exercises (de Oliveira Silva et al., 2020).

References

de Oliveira Silva, D., Pazzinatto, M. F., Rathleff, M. S., Holden, S., Bell, E., Azevedo, F., & Barton, C. (2020). Patient education for patellofemoral pain: a systematic review. journal of orthopaedic & sports physical therapy50(7), 388-396. https://www.jospt.org/doi/10.2519/jospt.2020.9400

Ma, K., Zhuang, Z. G., Wang, L., Liu, X. G., Lu, L. J., Yang, X. Q., … & Liu, Y. Q. (2019). The Chinese Association for the Study of Pain (CASP): consensus on the assessment and management of chronic nonspecific low back pain. Pain Research and Management2019https://doi.org/10.1155/2019/8957847

This is an informative post. Patient assessment was important in establishing the reasons for pain and other possible underlying conditions. Another differential diagnosis I would suggest is lumbosacral muscle strains/sprains. This is a condition associated with traumatic episodes. The pain increases with movement and alleviates with a limited range of motion and rest. The development of low back pain can be associated with the sensitization of nerve endings by releasing chemical mediators, in-growth of neurovascular into the degenerated disk, and alteration in the biomechanical properties of the disk structure (Ma et al., 2019). The development of an effective management plan in this case needs a refined subjective assessment to foster streamlining of physical examination. Interviewing the patient about the behavior of the symptoms and taking the history of the condition is vital in establishing the clinical rationale for the causal factors and causes of symptoms. The management plans frequent observation for regularity or reduction of pain, a sporadic repeat of CT scans and X-rays, and referring the patient to rehabilitation or a physical therapist for exercises (de Oliveira Silva et al., 2020).

References

de Oliveira Silva, D., Pazzinatto, M. F., Rathleff, M. S., Holden, S., Bell, E., Azevedo, F., & Barton, C. (2020). Patient education for patellofemoral pain: a systematic review. journal of orthopaedic & sports physical therapy50(7), 388-396. https://www.jospt.org/doi/10.2519/jospt.2020.9400

Ma, K., Zhuang, Z. G., Wang, L., Liu, X. G., Lu, L. J., Yang, X. Q., … & Liu, Y. Q. (2019). The Chinese Association for the Study of Pain (CASP): consensus on the assessment and management of chronic nonspecific low back pain. Pain Research and Management2019https://doi.org/10.1155/2019/8957847