Discussion Responses: Assessing Musculoskeletal Pain

Assignment:

*use peer-reviewed scholarly sources no older than 5 years old.

*Use 2 peer-reviewed scholarly sources for each student response.

  • The text/pdf book is not considered a scholarly source e.g. Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2018). Seidel’s Guide to Physical Examination. Mosby.

Respond to two of your colleagues 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.

Case study students responded to: Case #1: Back Pain

 A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What 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?

**First student Case Response to Case Study #1: Back Pain

Patient Information:

Initials: T.K Age: 42 y.o Sex: M Race: African American

S.

CC: Lower back pain

HPI: 42-year-old AA male presents with pain in his lower back for the past month. The pain is sharp and sometimes radiates to his left leg. The patient reports that pain occurs at any time and is worse with activity and feels better after taking Tramadol which was given to him at his last urgent care visit 2 weeks ago. However, the pain returns within a few hours, making ADLs a challenge. The patient rates the pain as 7/10.

 

Current Medications:

Pantoprazole 40mg twice a day for GERD

Amlodipine 10mg tablet daily for Hypertension

Atorvastatin 20mg tablet at bedtime for Hypercholesterolemia

Tramadol 50mg tablet every 6 hours as needed for back pain

 

Allergies:

Codeine from Percocet – Rash, itchiness

 

PMHx:

Hypertension

Hypercholesterolemia

GERD

Appendectomy -1998

 

Immunization status:

Influenza vaccine – 11/12/2020

Tetanus – 04/20/2020

All other vaccines up-to-date per patient record

Soc Hx:

Patient works as a cable technician for Verizon, working at least 60 hours a week, climbing ladders, and working on poles. Enjoys playing soccer on the weekend with friends, denies past and present tobacco or alcohol use. Denies illicit drug use. Lives with his wife and 3 children whom he describes as his support system in a single-family home in a suburban area. Attends a Presbyterian church on Sundays. Confirms safety at home and in the work environment.

 

Fam Hx:

Mother – Hypertension, osteoarthritis

Father – Diabetes, Hypertension

Maternal grandmother – breast cancer, osteoarthritis

Maternal grandfather – Hypertension

Paternal grandmother – Diabetes, Hypercholesterolemia

Paternal grandfather – Stroke

 

ROS:

GENERAL: No fever, chills, weakness, or fatigue. No recent weight changes.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.

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

SKIN: No rash or itching.

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

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain.

GENITOURINARY: No urinary retention, no burning on urination.

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

MUSCULOSKELETAL: Lower back pain radiating to the left lower extremity.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

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

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

 

O.

Physical exam:

VS: BP: 131/70 P: 85 R: 18 SPO2: 98% T: 97.8 F W:255 lbs

 

GENERAL: No fever, chills, weakness, or fatigue. No recent weight changes.

HEENT: Eyes: Eyes equal, symmetrical, PERRLA, No visual loss

Ears, Nose, Throat: No enlarged tonsils, nares pink, no discharge

SKIN: Warm, dry, no tenting

CARDIOVASCULAR: S1, S2 heart sounds, no murmurs, no gallops, regular pulse, bilateral upper extremity pulses palpable +2, bilateral lower extremity pulses palpable +2, No edema in bilateral lower extremities, capillary refill less than 3 secs

RESPIRATORY: Chest symmetrical, lungs clear in all fields, no cough

GASTROINTESTINAL: Abdomen rounded, soft, non-tender, bowel sounds normoactive in all 4 quadrants, scar on right lower abdomen from an appendectomy in 1998

GENITOURINARY: Kidney non-palpable

NEUROLOGICAL: sensitive to touch in all extremities

MUSCULOSKELETAL: normal lordotic curve, no bulging discs/enlarged boney areas, AROM in bilateral upper and lower extremities, increased pain with activity.

 

Diagnostic results:

CBC

CMP

X-ray of spine/lower back/lower extremities

CT of spine

MRI of spine

Electromyography (EMG)

 

A.

Differential Diagnoses:

  1. Sciatica
  2. Herniated disc
  3. Spinal stenosis
  4. Muscle strain
  5. Spondylolisthesis

 

 

Sciatica is my lead differential diagnosis because it is commonly used to describe radiating leg pain. Sciatic nerve pain is caused by inflammation or compression of the lumbosacral nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation (Jensen et al., 2019). To diagnose sciatica, a muscle strength and reflexes test which involves walking on toes or heels, rising from a squatting position, and, lifting each leg while lying on the back may be performed. Sciatica pain worsens with these activities (Mayo Clinic, 2020). However, one or more of the other differential diagnoses listed usually forms the root cause for sciatica because any condition that may structurally impact or compress the sciatic nerve may cause sciatica symptoms. The most common cause of sciatica is a herniated or bulging lumbar intervertebral disc. In the elderly population, lumbar spinal stenosis may cause these symptoms as well. Spondylolisthesis or a relative misalignment of one vertebra relative to another may also result in sciatic symptoms (Davis et al., 2021).

In clinical terms, Spondylolysis is an anatomical defect or fracture of the pars interarticularis of the vertebral arch, which occurs at the L5 vertebrae between 85 and 95% of the time and occurs at the L4 vertebrae 5–15% of the time. The defects can occur unilaterally or bilaterally (Gagnet et al., 2018). However, Spondylolysis is most common in adolescents, unlike the aforementioned conditions.

Additionally, lumbar or pelvic muscular spasm and/or inflammation may impinge a lumbar or sacral nerve root, also causing sciatic symptoms. A spinal or paraspinal mass including malignancy, epidural hematoma, or epidural abscess may also cause a mass-like effect and sciatica symptoms (Davis et al., 2021).

Sciatica is a clinical diagnosis, and therefore, a thorough history and physical examination such as the one provided are necessary for a complete evaluation and diagnosis. Imaging is initially of little value, however, if warranted, plain films of the lumbosacral spine may evaluate for fracture or spondylolisthesis. A non-contrast CT scan may be performed to evaluate fracture if plain films are negative.

Additionally, pain that has been persistent for 6 to 8 weeks and not responding to conservative management should be imaged. In this case, MRI is the imaging modality of choice. In cases where the neurologic deficit is the present or mass effect is suspected, immediate MRI is the standard of care in establishing the cause of the pain and ruling out pressing surgical pathology (Davis et al., 2021).

An X-ray of the spine may reveal an overgrowth of bone (bone spur) that may be pressing on a nerve, while an MRI produces detailed images of bone and soft tissues such as herniated disks. Additionally, an Electromyography (EMG) test can confirm nerve compression caused by herniated disks or narrowing of the spinal canal (spinal stenosis) (Mayo Clinic, 2020). With the appropriate imaging, an accurate diagnosis can be made and will determine the patient’s course of treatment.

 

References

Davis, D., Maini, K., & Vasudevan, A. (2021, February 26). Sciatica. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK507908/

Gagnet, P., Kern, K., Andrews, K., Elgafy, H., & Ebraheim, N. (2018). Spondylolysis and spondylolisthesis: A review of the literature. Journal of Orthopaedics, 15(2), 404–407. https://doi.org/10.1016/j.jor.2018.03.008

Jensen, R. K., Kongsted, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ, l6273. https://doi.org/10.1136/bmj.l6273

Mayo Clinic. (2020, August 1). Sciatica – diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/sciatica/diagnosis-treatment/drc-20377441

 

**Second student Case Response to Case Study #1: Back Pain

                              Episodic/Focused SOAP Note Template

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?

Patient Information:

Patient Initial:   CS1  Age: 42 Sex: Male Race: Unknown

S.

CC: Complaints of lower back pain.

HPI: CS1 is a 42-year-old male who presented to the clinic today with complaints of lower back pain. Pain sometimes radiates down left leg. Pain rated at 8/10 on worse days and 5/10 on best days. Took 800mg of Motrin every 6 hours with little relief.   

Current Medications: Ibuprofen 800mg every 6 hours for back pain; Protonix 40mg for acid reflux and heartburn; Metformin 500mg twice a day for Diabetes.

Allergies: No known drug allergies and no known food allergies.

PMHx: Reflux, Diabetes; Date of last Tetanus 04/10/2021Soc Hx: Maintenance worker at local hospital; enjoys fishing, hunting and rebuilding car motors. Married with five children, one in college and four in high school. Expressed safety mindset with occasional social drinks and does not smoke or use illicit drugs. Great family and friend support system voiced.

Fam Hx: Father is alive with HTN, DM, and EKD on dialysis. Mother is deceased with a history of HTN, CAD, and RA. Grandparents history unknown. Siblings have no history of illnesses or diseases. Children are healthy.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies chills, night sweats, and fever.

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

SKIN:  No rash or itching.

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

RESPIRATORY:  No shortness of breath, cough, or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No change in urinary systems.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, or ataxia. Admits to numbness or tingling in the left leg. No change in bowel or bladder control.

MUSCULOSKELETAL:  Admits to muscle and back pain. No joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

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

ALLERGIES: No Known Drug Allergies.

O.

Physical exam:

Vital Signs:

  • Temp 97.6
  • RR 20
  • BP 120/76
  • Height 5’8”
  • Weight 212

Skin: warm, dry, well nourished, with great tone.

Lungs: Lungs sounds clear bilaterally

Neurological: Awake, alert, oriented to person, place, and time (x3).

Cardiovascular: S1 and S2 present with regular rate.

Peripheral Vascular: Pulses +2 with no edema present

Abdomen: soft with active bowel sounds in all four quadrants

HEENT: No abnormalities noted

Musculoskeletal: Low back pain that radiates down left leg. Denies musculoskeletal injury.

Diagnostic results:

Labs returned normal; x-rays showed minor scoliosis; MRI of spine shows two herniated disks S1-L2;   

A.

Differential Diagnoses :

Herniated Disc: This condition is caused when a disk is out of place due to misuse. Often seen in people who lift heavy items or have jobs that rely heavily on their back strength. Therefore, the disk is herniated outside the vertebrae, which will sometimes place pressure on the nerves (Mbarki, et. al., 2020). I believe this is what the person is suffering from. Herniated disc often create compression on nerves which causes the numbness.

Spinal Stenosis – This is caused from the narrowing of the nerve spaces in the spine.  This creates pressure on the nerves and often cause tingling and numbness in the arms and legs (Zhang, et. at., 2021). This condition is often caused by overuse and long-term heavy strain on the back  

Degenerative Lumbar Spondylolithesis – This is a condition caused when one on your bones inside the spine slip forward. These can be found by x-rays supported by evaluation (Zhang, et. at., 2021).  

Muscle Strain – This is normally caused by some over use of the muscle, which causes tightening in the back. This condition can be found by physical examination and range of motion (Daniels, et. al., 2020).

Arthritis in the Spine – This is caused when arthritis is formed on the joints and inflammation has began in the joints.  This inflammation creates muscles tightness which compresses nerves (Miller, et. al., 2020)  

P.  

 

References

Daniels JM, Arguelles C, Gleason C, Dixon WH. Back Injuries. Prim Care. 2020 Mar;47(1):147-164. doi: 10.1016/j.pop.2019.10.008. Epub 2019 Oct 17. PMID: 32014131.

Mbarki, W., Bouchouicha, M., Frizzi, S., Tshibasu, F., Ben Farhat, L., & Sayadi, M. (2020). A novel method based on deep learning for herniated lumbar disc segmentation. 2020 4th International Conference on Advanced Systems and Emergent Technologies (IC_ASET), Advanced Systems and Emergent Technologies (IC_ASET), 2020 4th International Conference On, 394–399. https://doi-org.ezp.waldenulibrary.org/10.1109/IC_ASET49463.2020.9318261

Miller, M., Chalmers, P. N., Nyfeler, J., Mhyre, L., Wheelwright, C., Konery, K., Kawakami, J., & Tashjian, R. Z. (2020). Rheumatoid arthritis is associated with increased symptomatic acromial and scapular spine stress fracture after reverse total shoulder arthroplasty. JSES International, 5(2), 261–265. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jseint.2020.10.010

Zhang, D., Zhang, W., Zhou, X., & Jin, S. (2021). [Comparison of CLIF and TLIF in treatment of degenerative lumbar spondylolisthesis combined with lumbar spinal stenosis]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi = Zhongguo Xiufu Chongjian Waike Zazhi = Chinese Journal of Reparative and Reconstructive Surgery, 35(2), 210–216. https://doi-org.ezp.waldenulibrary.org/10.7507/1002-1892.202008092

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