Discussion: Assessing Muscoskeletal Pain
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provide the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the 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.
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?
Case 2: Ankle Pain
A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottowa ankle rules to determine if you need additional testing?
Case 3: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
To prepare:
- 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.
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 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.
Expert Solution Preview
Introduction:
Assessing musculoskeletal pain can be challenging due to the interconnectedness of the musculoskeletal system. It requires an evaluation process informed by the patient’s history and physical exam. In this discussion, three case studies have been presented that describe abnormal findings in patients seen in a clinical setting. The aim is to identify the causes of pain and evaluate the patient’s condition for proper treatment.
Answer:
Case 1: Back Pain
The patient, a 42-year-old male, is reporting pain in his lower back that radiates to his left leg. The nerve roots that may be involved in this case are L4 and L5. To test for L4, ask the patient to dorsiflex the foot. For L5, ask the patient to extend the big toe. Additional symptoms that need to be explored are numbness, tingling, and weakness in the leg. The differential diagnosis for acute low back pain based on the AHRQ guidelines are radiculopathy, nonspecific low back pain, spinal stenosis, compression fracture, and vertebral osteomyelitis. Physical examinations that need to be performed are a neurological exam, range of motion, and straight leg raise test. Special maneuvers that can be performed are the slump test and the crossed straight leg raise test.
Case 2: Ankle Pain
The patient, a 46-year-old female, is reporting pain in both ankles, but she is more concerned about her right ankle. The foot structures that may be involved are the lateral ankle ligaments, peroneal tendons, and Achilles tendon. Additional symptoms that need to be explored are swelling, bruising, and stiffness in the ankle. The differential diagnosis for ankle pain is a sprain, Achilles tendon rupture, peroneal tendonitis, and osteochondral lesion. Physical examinations that need to be performed are palpation, range of motion, and the anterior drawer test. Special maneuvers that can be performed are the squeeze test and the Thompson test. The Ottowa ankle rules can be applied to determine if additional testing is required.
Case 3: Knee Pain
The patient, a 15-year-old male, is reporting dull pain in both knees, clicking in one or both knees, and a catching sensation under the patella. Additional history that needs to be collected includes the onset of pain, any trauma, and swelling in the knee. The categories that can be used to differentiate knee pain are traumatic, nontraumatic, and systemic. The specific differential diagnoses for knee pain are patellofemoral pain syndrome, meniscal tears, ligament injuries, Osgood-Schlatter disease, and patellar tendonitis. Physical examinations that need to be performed are palpation, range of motion, and the Lachman test. The anatomic structures that need to be assessed as part of the physical examination are the patella, the quadriceps tendon, and the collateral ligaments. Special maneuvers that can be performed are the McMurray test and the Apley’s grind test.
In conclusion, the diagnosis of musculoskeletal pain requires a thorough evaluation process. For each case, appropriate diagnostic tests and special maneuvers need to be performed to identify the cause of pain. Evidence-based practice needs to be followed to direct the diagnosis and treatment process. Differential diagnosis helps narrow down the possibilities and provides a suitable treatment plan for the patient’s condition.
