NURS 6512 Week 8 Assessment of the Musculoskeletal System
NURS 6512 Week 8 Assessment of the Musculoskeletal System
S.
CC (chief complaint): “I feel pain in my ankles, but the right one is more intense.”
HPI:
R.K is a 46-year-old A.A female presenting with a chief complaint of pain in her ankles. She reports that the pain in the right ankle is more intense. The ankle pain began three days ago when she was playing soccer at the women’s soccer club in her church. She states that she heard a pop sound in her right ankle when playing, which was followed by a sudden intense pain on the right ankle, and she was unable to stand on the right foot. She has, however, been able to walk on the right foot, although it is uncomfortable. R.K also reports having some degree of tenderness and swelling on the right ankle. The ankle pain is aggravated by walking and relieved to some degree by OTC Tylenol, which she takes when the pain aggravates. She rates the pain on the left ankle as 3/10 and the right ankle as 6/10 on the pain scale.
Current Medications: OTC Tylenol 1 gm for pain.
Vitamin C supplements.
Allergies: Allergic to penicillin- causes rash, hives, and itchy eyes. No known food or seasonal allergies.
PMHx: Last Influenza shot-7 months ago. Last Tetanus- 3 years ago. No history of chronic illnesses. History of an appendectomy at 34 years. History of Tonsillectomy at 7 years.
Soc Hx:
R.K is a community youth counselor and has a diploma in Counseling. The patient is married. She currently lives with her spouse and three children aged 17, 14, and 8. Her hobbies include traveling and playing football. She is the captain of the women’s soccer club in her church and is the assistant coach for the junior girls’ soccer club. She reports taking wine occasionally but denies smoking tobacco or using illicit substances. She reports having a strict diet and taking about 7 glasses of water a day. The patient states that she has an active lifestyle and takes a morning run for about 40minutes at least 5 days a week. She also plays football on weekends. Her last health exam was 2 years ago. She states that her support system is her family and sisters.
Fam Hx: Family history of HTN- mother and maternal grandfather. History of breast cancer- paternal grandmother. The elder sister has a history of Asthma. Children are alive and well.
ROS:
GENERAL: Denies elevated body temperature, reduced energy levels, chills, or weight loss/gain.
HEENT: No history of head trauma, visual changes, hearing loss, ear discharge, nasal discharge/blockage, sneezing, or pain/difficulty swallowing.
SKIN: Denies color changes, itching, or lesions.
CARDIOVASCULAR: No history of swelling, chest discomfort, heart palpitations, or dyspnea at rest or exertion.
RESPIRATORY: No history of chest pain, cough, sputum, or dyspnea.
GASTROINTESTINAL: Denies appetite changes, nausea/ vomiting, abdominal discomfort, or diarrhea/constipation.
GENITOURINARY: Denies abnormal PV discharge, dysuria, or urinary frequency/urgency. LMP-3 weeks ago.
NEUROLOGICAL: Negative for dizziness, headache, paralysis, or burning sensations in the extremities.
MUSCULOSKELETAL: Positive for ankle pain and swelling. Limitations in movement. Denies joint stiffness/pain/enlargement.
HEMATOLOGIC: No history of bleeding or blood transfusion.
PSYCHIATRIC: Denies history of mental illnesses.
ENDOCRINOLOGIC: Negative for excessive perspirations, cold/heat intolerance, excessive urination, or acute thirst.
ALLERGIES: Allergic to penicillin.
O.
Physical exam:
VITAL SIGNS: BP- 126/74; HR- 98; RR-20; Temp-98.78 F
HT-5’4; WT- 136 pounds.
GENERAL: Neat and well-groomed female in no acute distress. Alert and oriented X4. Speech is clear and goal-directed. Maintains eye contact and exhibits a positive attitude.
CARDIOVASCULAR: Negative for JVD or edema. RRR; S1and S2 audible. No gallop sounds or murmurs heard on auscultations.
RESPIRATORY: Smooth and uniform respirations. Chest clear on auscultation.
MUSCULOSKELETAL: No skin color changes at the ankles.
Left Ankle- No bruising, swelling, or loss of function. Mild tenderness at the anterior aspects of the lateral malleoli. Negative ligamentous laxity with anterior drawer and talar tilt testing. Decreased total ankle motion of 2 degrees. No bony point tenderness. No difficulty bearing weight.
Right ankle- Bruising present. Moderate tenderness at the maximal points of the anterior (ATFL) aspect of the lateral malleoli on the right ankle. Positive anterior drawer test, negative talar tilt test- moderate joint instability. Some loss of function. Decreased total ankle motion of 7 degrees. Pain with weight-bearing and walking. No bony point tenderness.
Diagnostic results:
X-ray of the right ankle: An X-ray will be required to exclude fractures.
The Ottawa ankle rules indicate that ankle radiographs should be obtained in the event of pain in the malleolar region and any of the following: Pain on the posterior margin of the distal 6 cm or apex of the lateral malleolus; Pain on the posterior margin of the distal 6 cm or apex of the medial malleolus; and Incapacity to bear weight right away after an injury and for four steps during the assessment (Wells et al., 2019).
A.
Differential Diagnoses
Acute Lateral Ankle Sprain
An ankle sprain entails an inversion-type twist of the foot, accompanied by pain and edema. Lateral ankle sprains are the most prevalent injury in physically active populations, primarily among teenagers and young adults (Herzog et al., 2019). Clinical features of ankle sprains include pain, tenderness, swelling, bruising, muscle spasm, and cold foot or paresthesia, which suggest possible neurovascular compromise (Herzog et al., 2019). According to Wells et al. (2019), ankle sprains are categorized as Grade I, II, and III. Grade I have minimal tenderness and swelling, no loss of function, decreased total ankle motion of 5 degrees and below, and swelling of 0.5 cm or below as measured by figure-of-eight testing.
Grade II is characterized by bruising, moderate tenderness, a decreased ROM between 5-10 degrees, moderate swelling of 0.5-2.0cm, and ankle instability (Wells et al., 2019). Grade III presents with bruising, significant swelling of greater than 2.0 cm, near-total loss of function, ankle instability, extreme point tenderness, and decreased ankle ROM > 10 degrees.
Acute Lateral Ankle Sprain is the presumptive diagnosis based on the positive findings in the right ankle, including bruises, some loss of function tenderness at the anterior aspect of the lateral malleoli, moderate joint instability, reduced ROM of 7 degrees, and pain with weight-bearing and walking. The right ankle symptoms are consistent with a grade II lateral ankle sprain.
Acute Achilles tendon ruptures
Individuals with an Achilles tendon rupture often present with a primary symptom of a sudden snap in the lower calf accompanied by acute, severe pain. According to Egger and Berkowitz (2017), Achilles tendon rupture commonly occurs in healthy, active, young- to middle-aged persons, mostly from 37 to 43.5 years old. Patients often report experiencing a popping or giving way feeling in their posterior heel after pushing off (Egger & Berkowitz, 2017). Immediate pain occurs but slowly resolves, leaving a person with difficulty with plantar flexion, weight-bearing, or limping. Besides, the person cannot stand their toes on the affected side (Egger & Berkowitz, 2017). Achilles tendon rupture is a differential diagnosis based on findings of ankle pain, popping sensation that occurred during the ankle injury, and difficulties with bearing weight.
Right Ankle Fracture
While lateral ankle sprains comprise 90% of all ankle injuries, whereas an ankle fracture occurs only in 15% of the injuries, ankle fractures occur due to a twisting mechanism sustained from a low-energy injury (Lawson et al., 2018). A fractured ankle presents with severe pain, swelling, ecchymosis, and soft tissue injuries, such as abrasions and lacerations. Other features include loss of function, limited range of motion, compromised neurovascular status, and positive talar tilt and drawer testing (Lawson et al., 2018). A Right Ankle fracture is a differential diagnosis based on pertinent positives of pain, bruising, loss of function, reduced ROM, and positive talar tilt and drawer testing indicating joint instability.
References
Egger, A. C., & Berkowitz, M. J. (2017). Achilles tendon injuries. Current reviews in musculoskeletal medicine, 10(1), 72–80. https://doi.org/10.1007/s12178-017-9386-7
Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610. https://doi.org/10.4085/1062-6050-447-17
Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018). Ankle fracture-dislocations: a review. Foot & Ankle Orthopaedics, 3(3), 2473011418765122. https://doi.org/10.1177/2473011418765122
Wells, B., Allen, C., Deyle, G., & Croy, T. (2019). MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES. International journal of sports physical therapy, 14(3), 445–458. https://doi.org/10.26603/ijspt20190445
A 46-year-old man walks into a doctor’s office complaining of tripping over doorways more frequently. He does not know why. What could be the causes of this condition?
Without the ability to use the complex structure and range of movement afforded by the musculoskeletal system, many of the physical activities individuals enjoy would be curtailed. Maintaining the health of the musculoskeletal system will ensure that patients live a life of full mobility. One of the most basic steps that can be taken to preserve the health of the musculoskeletal system is to perform an assessment.
This week, you will explore how to assess the musculoskeletal system.
Learning Objectives
Students will:
- Evaluate abnormal musculoskeletal findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system
- Evaluate musculoskeletal X-Ray imaging
Learning Resources
Required Readings (click to expand/reduce)
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.
- Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
- Chapter 22, “Musculoskeletal System”This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
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.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)
- Chapter 3, “SOAP Notes”This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.
Required Media (click to expand/reduce)
Musculoskeletal System – Week 8 (12m)
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Discussion: Assessing Musculoskeletal Pain
Photo Credit: Getty Images/Fotosearch RF
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?
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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.
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.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 8 Discussion Rubric
Post by Day 3 of Week 8 and Respond by Day 6 of Week 8
To Participate in this Discussion:
Week 8 Discussion
Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination
A description of symptoms alone is not enough to form an accurate diagnosis of musculoskeletal conditions. Before forming a diagnosis, advanced practice nurses need to perform a physical examination. Although the musculoskeletal examination is relatively simple, it still needs to be performed multiple times before it can be mastered.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing a musculoskeletal examination this week.
Note: This is a practice physical assessment.
To Prepare
- Arrange an appropriate time and setting with your volunteer “patient” to perform a musculoskeletal examination.
- Download and review the Musculoskeletal Checklist provided in this week’s Learning Resources as well as review the Seidel’s Guide to Physical Examination online media.
The Lab Assignment
Complete the following in Shadow Health:
- Musculoskeletal (Practice)
What’s Coming Up in Week 9?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine appropriate methods for assessing the cognition and the neurologic systems during your Discussion. You also will complete the last assessment, Comprehensive (Head-to-Toe) Physical Assessment. Once again, you will conduct this assessment in the Digital Clinical Experience using the simulation tool, Shadow Health. Make sure to plan your time accordingly.
Week 9 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time.
Next Week