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NURS 6512 Assessing Musculoskeletal Pain

NURS 6512 Assessing Musculoskeletal Pain

NURS 6512 Assessing Musculoskeletal Pain

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A 15-year-old Caucasian male Justin Timberland presents to the clinic with reports of dull pain in both knees. He states sometimes one or both knees click, and he describes a catching sensation under the patella.

To start assessing my patient’s knee pain, I’ll approach the interview with “a useful framework to differentiate whether the limb pain involves symptoms caused by musculoskeletal injury, musculoskeletal or joint disease, systemic disease, or a combination of factors.” Pain can be caused by a direct reaction in tissues, a secondary reaction in adjacent tissues, a proximal or distal lesion, or organs such as the heart or kidney.” (Dains,2019.p.1.) . Knowing this, I decided to begin with a Focused history, in which I would ask the patient questions such as, does he have any of the common childhood bone diseases that would make him prone to bone injury or pain, i.e. Osteogenesis Imperfecta, also known as brittle bone disease, as it is usually diagnosed at birth as a bone is broken during the delivery process, from the fetus traveling down the bony structures of the birth canal? I’ll then ask him if the pain is the result of an injury. If it was an injury, how did it happen? Is this a new injury, or is it a recurrence of an old one? Finally, I’ll ask him to rate his pain on a scale of 0 to 10, with 0 being the least pain and 10 being the most pain.

Chief Concern (CC): I’ve been having dull pain in both of my knees, and I have also noticed that my knee and sometimes both of them click.”
History of Physical Illness (HPI): 15-year-old male patient presents today with a history of dull pain in both knees. The patient is concerned that one or both knees intermittently click, and he feels something catch below the patella (Walden University, n.d.).
Additional History Needed to Determine Cause of Knee Pain:
As a future APRN, it would be important to know if the patient’s pain is acute or chronic. I would use a mnemonic, such as OLDCARTS, to guide me as I interview the patient (Ball et al., 2019). Questions that I would want to know from the patient would include: Does the clicking sound occur with knee movement? How often does the clicking sound occur? Has the patient sustained any recent injuries? I would be interested to know what makes the pain worse and better. Additionally, I want to know the treatments the patient has used for his knee pain (e.g., rest, ice [or heat], elevate, immobilize, non-steroid inflammatory drugs, or acetaminophen). I would conduct the interview with the parent or caregiver out of the room, and then with the patient’s permission, ask the parent for more information.
Categories to Differentiate Knee Pain:
There are different categories to differentiate knee pain: bones, cartilage, ligaments, muscles, and tendons (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], n.d.). Each of these categories has conditions with clinical presentations, such as arthritis (bones and cartilage), chondromalacia and meniscus injury (cartilage), anterior and posterior cruciate ligaments injuries (ligament), tendinitis (tendon), and more (NIAMS).

Medications:

• Name, dosage, frequency, indication for taking medication, and last dosage should be noted.
• Medications should include prescribed, over the counter, vitamins, minerals, supplements, and complementary alternative medications (Ball et al., 2019).
Past Medical History (PMH):
• Recent trauma
• Cancer
• Connective tissue disorders (e.g., Marfan’s syndrome)
• Juvenile Rheumatoid Arthritis
• Hemophilia
• Osteoporosis
• Renal
• Neuromuscular disorders
• Neurological disorders
Past Surgical History (PSH):
• Orthopedic surgeries or procedures, such as arthroplasty
Family History [FH]: (Ball et al., 2019)
• Arthritis
• Abnormalities of the hips, knees, or feet
• Osteogenesis imperfecta
• Hypophosphatemia
• Hypercalciuria
• Marfan’s Syndrome

Social History (SH)

Information needs to be collected regarding the patient’s usage of tobacco products, alcohol, or illicit drugs. It is essential to get a baseline assessment of the patient’s usual activity of daily living. Is the patient involved in organized sports (e.g., soccer, football, baseball, basketball, martial arts)? I would also gather information about the patient’s average diet, including a balanced diet with protein and nutrients to help heal his condition.

Allergies:

• Allergies to prescribed medications, over-the-counter medications, vitamins, minerals, and supplements should be noted with the type of reaction and severity.
Immunizations:
• Review of current immunizations that should include last T-dap, Influenza, and COVID-19 boosters, and vaccines.
Review of Systems (ROS)

General

• Recent fatigue, malaise, fever, chills, night sweats, unusual bruising, unusual bleeding, and unintentional weight loss will need to be asked of the patient.
Cardiovascular:
• Inspection, percussion, palpation, and auscultation of the heart are part of all focused episodic exam.
Pulmonary:
• Inspection, percussion, palpation, and auscultation of the lungs are also part of a focused episodic exams.
Musculoskeletal:
• Inspection, percussion, palpation, and auscultation of both knees will be performed.
Physical Examination Performed (Ball et al., 2019)
• Inspect knees for symmetry, concavity, and contour in the flexed and extended positions.
• Observe the patient’s lower legs for alignment, specifically the femur and tibial angle should be at or less than 15 degrees to rule out either genu valgum or genu varum.
• Palpate popliteal and joint space in the flexed and extended positions.
• Test the patient’s range of motion (e.g., flexion-130 degrees, extension-0 to 15 degrees).
• Test the patient’s strength during flexion and extension while providing oppositional force against movement.
Anatomic Structures Being Assessed (Ball et al., 2019)
• Patella
• Meniscus
• Anterior and Posterior Cruciate Ligaments
• Lateral and Medial Ligaments
Special Maneuvers Performed (Lee et al., 2017; Ball et al., 2019)
• Hughston’s Plica Test
• Strutter Test
• Ballottement test
• Bulge test
• McMurray Test
• Apley Test
• Thessaly Test
• Anterior and Posterior Drawer Test
• Lachman Test
• Varus and Valgus Stress Tests

Objective

Vital Signs: (VS) height, weight, body/mass index (BMI), or vital signs
General: patient’s race, patient’s preference for gender identity will be ascertained.
Cardiovascular: The patient’s heart sounds (e.g., nl S1, nl S2, S3, S4), murmurs (e.g., type and location), adventitious sounds, clubbed fingers, capillary refill, jugular vein distension, carotid bruits or thrills, pedal edema would be noted in this section.
Pulmonary: Breath sounds in all areas of the anterior and posterior lungs (e.g., bronchial, bronchovesicular, vesicular, dull, resonant, and hyper-resonant) would be noted.
Musculoskeletal- symmetry, skin condition (e.g., bruising), swelling, pain with range of motion, and effusion around knee should be noted.

Diagnostic Tests:

• Radiograph of knees would be indicated this patient if it was determined his condition was secondary to an acute knee injury with the following findings: tenderness at fibula head, patella tenderness that is isolated, and the inability of the patient to flex his knee at a 90-degree angle (Ball et al., 2019). The patient has bilateral knee pain, which decreases the probability of malignancy; however, I would consult with my preceptor regarding ordering X-rays of his knees to rule out bony pathology.
• An MRI may be indicated if the patient has an injury to the medial or lateral meniscus and to the anterior or posterior cruciate ligaments (Rastegar et al., 2016). I would consult with my preceptor if the patient had a positive McMurray test before ordering an MRI. Additionally, if the patient’s symptoms did not improve with therapy, I would again consult with my preceptor about ordering an MRI for this patient.
• CBC with differential-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Sedimentation rate-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Anti-nuclear antibody test- if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Rheumatoid factor- if indicated depending on the patient H&P’s (Thatayatikom, 2021).

Assessment

Differential Diagnosis according to Song et al. (2018); Lee et al. (2017):
1. Synovial Infrapatellar Plica Syndrome of the knee is associated with anterior knee pain and clicking or popping sounds (Casadei & Kiel, 2021). The authors report that plica, a thick fibrotic band of tissue extending from a synovial joint, most commonly the knee[s] becomes inflamed due to overuse. Bilateral anterior knee pain is common. This patient has clicking sounds with pain around the knees. This diagnosis needs to be supported by more evidence from the history and physical of the patient.
2. Medial or Lateral Meniscal Tears are associated with knee sounds such as clicking, catching, and locking around the knee (Bhan, 2020). The author reports meniscal tears are common, and MRIs are inevitably required to confirm a diagnosis. This patient has bilateral clicking noise and a sensation of catching to the back of his knees.
3. Patellar Tendinopathy, commonly referred to as ‘Jumpers Knee’ is caused by small tears to the patella tendon that can be painful (Santana et al., 2021). The authors note this condition is seen with sporting activities that require jumping. The patient is complaining of dull pain in both knees. It is essential to gather more subjective and objective data from this patient and possibly his parents for an accurate working diagnosis.
4. Patellofemoral pain syndrome is characterized by anterior knee pain reproduced with running, climbing, and squatting (Bump & Lewis, 2021). The authors report patients generally describe an achy pain located around the knee. This diagnosis is part of the differential because the patient is experiencing pain around the knee. However, more information is required to give a presumptive diagnosis.
5. Anterior Cruciate Ligament Sprain or Tear is considered the most common injury to a knee ligament associated with sporting activities such as football, soccer, and basketball (Evans & Nielson, 2021). The authors state that the injury sustained to the ACL is most commonly a non-contact injury seen with skiers, soccer players, and basketball players from rotational movements. Patients generally complain of a popping sound and the knee giving out (Evans & Nielson). The patient is not complaining of a popping sound but rather a clicking sound with a catching sensation under the patella. This diagnosis is less likely because of the patient’s clinical presentation.
6. Juvenile Rheumatoid Arthritis (JRA) is diagnosed in patients younger than 16 years of age with joint and soft tissue pain (Thatayatikom, & Modica, 2021). An inflammatory, autoimmune process must be considered, especially if there is a family history of autoimmune disorders.
7. Osteochondrosis is also known as Osgood Schlatter disease, is a frequent cause of adolescent knee pain (Smith & Varacallo, 2020). The authors state it is caused by repetitive athletic movements seen more often in boys 12 to 14 years of age. They report that patients complain of anterior knee pain caused by microvascular tears and swelling when a piece of the tendon pulls away from the patella (NIAMS, n.d.). This diagnosis is less likely because the patient is complaining of dull bilateral pain to the knees, and he is not complaining of a bony bump to his kneecap, which is common with this disorder.
Primary Diagnosis/Presumptive Diagnosis
• Synovial Infrapatellar Plica Syndrome.
Plan
This section is not required for the assignment in this course (NURS 6512) but will be required for future courses.

References

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.). Elsevier.
Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus,
12(6), e8590. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359983/
Bump, J.M., & Lewis, L. (2021, May 8). Patellofemoral syndrome. In: StatPearls. StatPearls
Publishing. http://www.ncbi.nlm.nih.gov/books/NBK557657/
Casadei, K., & Kiel, J. (2021, April 19). Plica syndrome. In: StatPearls. StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK535362/
Evans, J., & Nielson, J.L. (2021, February 19). Anterior cruciate ligament knee injuries. In:
StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499848/
Lee, P., Nixon, A., Chandratreya, A., & Murray, J.M. (2017). Synovial plica syndrome of the
knee: A commonly overlooked cause of anterior knee pain. Surgery Journal, 3(1), e9-e16. https://doi.org/10.1055/s-0037-1598047
National Institute of Arthritis and Musculoskeletal and Skin Diseases. (n.d.). Knee problems.
https://www.niams.nih.gov/health-topics/knee-problems#tab-symptoms
Rastegar, S., Motififard, M., Nemati, A., Hosseini, N.S., Tahririan, M.A., Rozati, S.A., Sepiani,
M., & Moezi, M. (2016). Where does magnetic resonance imaging stand in the diagnosis of knee injuries? Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 21,(52).

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assessing Musculoskeletal Pain

NURS 6512 Assessing Musculoskeletal Pain
NURS 6512 Assessing Musculoskeletal Pain

https://doi.org/10.4103/1735-1995.187256
Santana, J.A., Mabrouk, A., & Sherman, A.L. (2021, March 17). Jumpers Knee. In: StatPearls.
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532969/
Smith, J.M., & Varacallo, M. (2020, July 29). Osgood Schlatter disease. In: StatPearls,
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441995/
Song, S.J., Park., C.H., Liang, H., & Kim, S.J. (2018). Noise around the knee. Clinics in
Orthopedic Surgery, 10(1), 1-8. https://doi.org/10.4055/cios.2018.10.1.1
Thatayatikom, A., & Modica, R., & de Leucio, A. (2021, January). Juvenile idiopathic arthritis.
In: StatPearls, StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK554605/
Walden University. (n.d.). Case 3: Knee pain: Advanced health assessment. www.waldenu.edu.

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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?

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?
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

Rubric Detail

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Content
Name: NURS_6512_Week_8_Discussion_Rubric
• Grid View
• List View
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.

Subjective

CC: Lower back pain

HPI: Hispanic male patient JM, age 42, presented to the clinic today complaining of severe lower back pain over the past month. Periodically, the pain travels along his left leg. He felt a sharp, throbbing pain in his left lower leg, along with a tingling feeling. He said the ache in his back was an eight out of ten. He feels more discomfort when he lifts heavy objects, bends, or sits for lengthy periods of time. He says over-the-counter ibuprofen helps a little.

Current Medications:

OTC Ibuprofen 400mg Q4hrs as needed for pain.

Claritin 10mg daily for allergies

Lisinopril 5mg daily for hypertension

Allergies: No known drug allergy; environmental allergies: Pollen (Reaction- sneezing and watery eyes).

PMHx: Medical history includes hypertension 5 years ago. No hospitalizations. His vaccinations are all current.

Past surgical Hx: No surgical history reported.

Social Hx: JM has a high school diploma and is employed as a bricklayer for a local construction company. He is married and resides in a three-bedroom home with his wife and 10-year-old son. For the last ten years, he has been smoking one pack of cigarettes per day. He denied consuming alcohol or using illegal substances. Because of his back pain, he refuses to exercise on a regular basis. He follows a healthy diet that includes fruits and vegetables.

Family Hx: Mother is 65 years old, living, and has been diagnosed with high blood pressure and high cholesterol. His father is 70 years old, living and suffering from hypertension and benign prostatic hyperplasia. Grandpa on the mother’s side passed away at age 64 due to heart attack complications. Maternal grandmother died at age 73 from asthma and diabetes related problems. His paternal grandfather passed away at age 71 due to COPD-related illnesses. His paternal grandmother was 55 years old when she passed away from lung cancer. At the age of 45, one sibling was diagnosed with multiple sclerosis. One healthy kid of 10 years old.

ROS:

General: Reported intermittent tingling and numbness in the left limb. No reports of fever, chills, or weight loss.

HEENT: Denies head injury, blurred vision, hearing loss. No changes in smell or taste reported. No complaints of epistaxis.  No sore throat was reported.

Skin: No skin lesion, mole, or rash.

Cardiovascular: No reports of heart murmur, chest discomfort, and irregular heartbeat.  No edema in the extremities.

Respiratory: No reports of cough or dyspnea.

Neurological: Denies migraines, fainting, or convulsions. No reports of coordination problems.

Musculoskeletal: Pain in the lower back and sometimes in the left leg. Denies that other parts of the body have swollen joints or muscle pain.

Hematologic/Lymphatic: Denies bleeding or bruising. Denies enlarged nodes or history of splenectomy.

Endocrine: No heat or cold intolerance reported. No c/o polydipsia or polyuria.

 Objective

Physical Exam:

General: Patient is alert and oriented x3. He is calm and answers interview questions appropriately. He is well-nourished and well- developed. He reports weakness to the left lower extremity.

Vitals: BP- 145/88mmHg; HR- 90bpm and regular; Resp- 19bpm and regular; Temp- 98.5F orally; SPO2 99%R/A; Height- 5’8”; Weight- 166lbs; BMI- 25.2.

Skin: Turgor is good. No rashes or lesions.

HEENT: Head is normocephalic. PERRLA. Conjunctivae negative for exudate and hemorrhage. External auditory canal is patent. Ears are nontender and not swollen. Nares are patent. Nasal mucosa is pink without drainage. Oral mucosa is moist, pink with no lesions. No tonsillar swelling, no pharyngeal swelling.

Cardiovascular/peripheral Vascular: Presence of S1S2 heart sounds during auscultation; no murmurs. Heart rate regular rhythm. Peripheral pulses 2+ symmetrical bilaterally. No peripheral edema.

Respiratory: Chest symmetrical. No adventitious lung sound auscultated.

Gastrointestinal: Abdomen is symmetrical. Normoactive bowel sounds x four quadrants. Abdomen is soft, nontender. No palpable masses.

Musculoskeletal: Low back pain with flexion, extension, and twisting. Limited ROM to lower extremities. No sign of trauma to lower back.

Neurological: Alert and oriented x3. Appropriate affect and mood.

Diagnostic Test:

  1. Complete blood count (CBC) to verify infection (high WBC count).
  2. Erythrocyte sedimentation rate (ESR) to detect inflammation.
  3. A computed tomography (CT) scan to detect unusual tissues and analyze the patient’s spinal status.
  4. Imaging of the spinal cord and nerves using (MRI) magnetic resonance imaging (Dains et al., 2019).

 Assessment

Differential Diagnosis:

  1. Lumber disc herniation (LDH): Lumbar disc herniation is defined as the movement of disc material (annulus fibrosis or nucleus pulposus) over the intervertebral disc area, causing low back and/or leg pain (Yang et al., 2022). It usually starts with lower back discomfort that spreads down one leg and is often followed by sensations of numbness or tingling in the lower leg. The symptoms of LDH correspond to the patient’s chief concern.
  2. Sciatica: Sciatica is characterized by radiating and tingling pain down the leg and lower back caused by inflammation or compression of the lumbosacral nerve roots (Jensen et al., 2019). Furthermore, sciatica is frequently brought on by a herniated spinal disk, excessive movement, or heavy lifting, according to Dains et al. (2019). The patient is overweight, and his job requires heavy lifting and recurrent movements, which may contribute to his lower back pain.
  3. Lumber Spinal Stenosis (LSS): Lumbar spinal stenosis (LSS) is a degenerative disc condition that causes the area encompassing the vertebrae’s neurovascular systems to narrow (Fishchenko et al., 2018). Symptoms of nerve inflammation or compression include discomfort and weakness or numbness in the legs. A history, physical examination, and imaging studies are used to make the diagnosis. The assessment should concentrate on leg or buttock pain while ambulating and stretching to alleviate symptoms (Chagnas et al., 2019).
  4. Piriformis Syndrome (PS): Muscle spasm in the piriformis and/or irritation of the sciatic nerve in the area are the root causes of piriformis syndrome, as stated by Siddiq & Rasker (2019). Physical examination, patient history, and imaging studies like x-rays are used to determine the diagnosis of PS. The authors indicated that the flexion-adduction-internal rotation test, the Pace sign, and the Freiberg techniques are used to identify individuals with PS. Pain and weakness by resisted abduction and external rotation of the hip while seated suggests signs of Pace. The Freiberg sign manifests as pain and weakness with passive forced internal rotation of the hip in a supine position.
  5. Lumbar spondylolisthesis: Low back pain, lower limb radiating pain, and sporadic neurogenic claudication are symptoms of lumbar spondylolisthesis, a degenerative condition of the lumbar spine (Wang et al., 2022). The patient’s symptoms match the above statement, too.

References

Chagnas, M.-O., Poiraudeau, S., Lef vre-Colau, M.-M., Rannou, F., & Nguyen, C. (2019).

Diagnosis and management of lumbar spinal stenosis in primary care in france: A survey

of general practitioners. BMC Musculoskeletal Disorders, 20(1).

https://doi.org/10.1186/s12891-019-2782-y

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.

Fishchenko, I. V., Kravchuk, L. D., & Perepechay, O. A. (2018). Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-

analysis of literature data). Pain Medicine, 3(1), 18–32. https:// doi -org.ezp.waldenulibrary.org/10.31636/pmjua.v3i1.83

Jensen, R.K., Kongstead, A., Kjaer, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ. 16273.

https://doi.org/10.1136/bmj.16273

Siddiq, M. B., & Rasker, J.J (2019). Piriformis pyomyositis, a cause of piriformis syndrome-a systematic search and review. Clinical

            Rheumatology, 38(7), 1811-1821. https://doi.org/10.1007/s10067-019-04552-y

Wang, P., Zhang, J., Liu, T., Yang, J., & Hao, D. (2022). Comparison of degenerative lumbar

spondylolisthesis and isthmic lumbar spondylolisthesis: Effect of pedicle screw

placement on proximal facet invasion in surgical treatment. BMC Musculoskeletal

            Disorders, 23(1). https://doi.org/10.1186/s12891-021-04962-7

Yang, S., Shao, Y., Yan, Q., Wu, C., Yang, H., & Zou, J. (2021). Differential diagnosis strategy

between lower extremity arterial occlusive disease and lumbar disc herniation. BioMed

            Research International, 2021, 1–5. https://doi.org/10.1155/2021/6653579

I thought your analysis of this case study was on point.

Analysis of Differential Diagnoses:

Right Ankle Sprain: The most likely diagnosis is this. Sprains of the ankle involve the ligaments being stretched or torn. The patient suffered this type of injury during soccer due to sudden force to the ankle. Physical examination also reveals swelling, tenderness, and decreased range of motion in the right ankle. Another point worth noting when formulating the differential diagnosis between an ankle sprain and an inflammatory or infectious process is that an ankle sprain usually does not cause systemic symptoms, for example, a fever.

Anterior Talofibular Ligament Rupture: This is a specific type of ankle sprain in which the anterior talofibular ligament (ATFL), a critical ligament on the outside of the ankle, is torn. A ligament rupture would be consistent with the patient’s audible “pop” description. This diagnosis is also supported by swelling and tenderness over the lateral malleolus.

An ATFL rupture may explain the patient’s severe symptoms. Avulsion Fracture of the Lateral Malleolus: This is a less likely diagnosis, but the mechanism of injury and the patient’s symptoms do not rule it out. An avulsion fracture occurs when the forceful pull of a tendon or ligament tears away a fragment of bone. Given the sudden inversion force to the patient’s ankle and her report of an audible “pop,” it is possible that an avulsion fracture could have occurred. Physical examination findings of tenderness and swelling over the lateral malleolus also consider this. An x-ray would be needed to diagnose or rule out this condition definitively.

All of the patient’s physical exam, injury, and symptoms seem reasonable. A diagnostic imaging test would be the next step. An ankle X-ray is a valuable tool that provides clarity.

Based on the patient’s history of injury during a soccer game, the sudden onset of pain, the description of an audible “pop,” and the physical examination findings, the most likely diagnosis is a right ankle sprain. Ankle sprains are common in athletes and individuals who engage in sports activities, as in this patient’s case. The specific involvement of the Anterior Talofibular Ligament (ATFL) should be a particular consideration, given the physical exam findings.

While all three conditions on the differential list could produce the patient’s symptoms, a right ankle sprain (possibly involving the ATFL) is the most likely, given the mechanism of injury, the absence of other significant findings on the review of systems, and the physical examination findings. An avulsion fracture is a potential concern, but an ankle x-ray would confirm or refute this diagnosis. If the x-ray does not show a fracture and the patient’s symptoms persist or worsen, more advanced imaging, for example, a CT scan or MRI, may be needed to evaluate for ligament damage, especially if there is suspicion of a rupture of the ATFL.

 

References

The 2023 Osteoarthritis Clinical Trial and Research Guide. Policy Lab. (2023, October 17). https://policylab.us/clinical-trials/osteoarthritis/

McKechnie, D. D. (2023, July 19). Osteoarthritis: Causes, symptoms, and treatment. Patient.info. https://patient.info/bones-joints-muscles/arthritis/osteoarthritis

 Review of Case Study 2

 

Focused SOAP Note for a patient with ankle pain

Patient Information:

S.J. is a 46-year-old African American female.

Subjective

CC (chief complaint): “My ankles hurt, but it is much worse on the right side.”

HPI: S.J. is a 46-year-old African American female who presents to the clinic with bilateral ankle pain for the past 3 days. The pain started after she played soccer over the weekend and noticed a pop sound while playing. The pain feels like it is throbbing and achy. She can bear weight on both ankles but noticed worse discomfort on the right side. Her pain is 3/10 in the left ankle but 6/10 on the right side. Elevation and ice have provided relief, but her right ankle has become swollen. Her pain is 6/10 on her right ankle and 3/10 on the left side.

Current Medications:  Metformin 500 mg PO BID, Multivitamin PO daily, Ibuprofen 400 mg PO every 6hrs PRN, Tylenol 500 mg PO every 6 hrs. PRN, Oral contraceptive I tablet PO daily.

Past Medical History: Diabetes mellitus type 2.

Family History: Mother has type 2 diabetes mellitus (controlled) and hypertension. Father has arthritis. Maternal grandmother has type 2 diabetes. Maternal grandfather had hypertension and died due to a stroke at 62. The paternal grandmother was diagnosed with recurrent UTI. My paternal grandfather has arthritis. My Sister and brother both have type 2 diabetes mellitus. Two children are healthy with no medical history.

Social History: S.J has a husband of 20 years and two children, a 15-year-old son and 13-year-old daughter. The family lives together in their private home and family support. Employed full-time as an accountant. She exercises five days a week and denies any alcohol, tobacco, or illicit drug use. Uses a seat belt while driving and not use of cell phone while driving.

Allergies:  Hydromorphone (Dilaudid), Nausea, and vomiting                  .

Immunization:  Influenza vaccine October 2022. Tetanus June 2020. Covid19 vaccine X2 doses of Pfizer in March of 2022

 

Review of Systems

HEENT

Head: Head is symmetrical and normal in size.

Eyes: Denies light sensitivity, cloudy vision, drainage, double vision, or blurry vision.

Ears: No discharge from ears, tinnitus, swelling, or impaired hearing.

Nose: denies nasal congestion, drainage, packing, postnasal drip, or nosebleed.

Neck: no tenderness, swelling, and no pain, or injury.

Throat: Denies pain while swallowing, cough, or enlarged tonsils.

Cardiovascular: No edema, difficulty breathing, palpitations, orthopnea, murmur, gallop, or Arrhythmias.

Neurological: Alert and oriented, denies any dizziness, headaches, seizures, or problems with coordination, numbness and tingling in all extremities.

Musculoskeletal: Bilateral ankle pain that is more severe on the right ankle. Limited range of

Lymphatics: No cervical lymphadenopathy, no Hx of splenectomy, or enlarged nodes motion on both lower extremities, mainly on the right. Swollen right foot.

 

Objective

Physical Exam:

Vital Signs:  Temp 97.8 oral, P 72, BP 135/78, R 16 unlabored, Wt.: 168 lbs., Ht: 5’9″. BMI 25.

 

General: Alert and Oriented x4. Complaints of pain.  She is Pleasant, calm, and cooperative.  Dressed appropriately and well-groomed and well developed. Appears her age.

HEENT:

Head: No trauma or headache.

Eyes: No edema, drainage, or crust. Pink conjunctiva and white sclera.

Ears: No hearing aids, negative for ecchymosis, laceration, external trauma, drainage, swelling or pain.

 Nose: No nasal drainage, congestion, or postnasal drip.

Neck: Symmetrical, no tracheal deviation, tenderness, mass, or rigidity. Oronasal pharynx clear.

Heart/Peripheral Vascular: S1 & S2 noted. No murmurs. My right ankle with ecchymosis and edema. Left ankle no edema. Bilateral posterior tibial pulses. No thrill 2+. Bilateral dorsalis pedis pulses no thrill 2+. Capillary refill in hands and feet in less than 3 seconds.

Musculoskeletal: Right ankle edema with 2x2cm ecchymosis on mid-lateral malleolus area with tenderness with palpitation on the lateral side. Range of motion with pain in bilateral ankles and limitations with dorsiflexion, plantar flexion, and inversion. Positive pain on rotation of ankles bilaterally with worsening pain on the right. No bony tenderness, deformity, or crepitus.

Neurological: Alert and oriented x4. Negative for headache, dizziness, and seizures. Strength and sensation are intact bilaterally in the upper and lower extremities, with some weakness noted at the right ankle.

Skin/Lymph Nodes: Skin is dry, warm, and intact. The right ankle has ecchymosis on the lateral malleolus area.

Diagnostic results: X-rays and MRI are to determine an early diagnosis and treatments and prevent chronic pain. These tests should be performed on the areas, including 6 cm of the posterior and tip of the lateral and mid malleolus. The Ottawa Ankle rules would be observed to identify the necessity for diagnostic testing in the patient suffering from ankle pain. This tool helps identify an ankle fracture with a 98.5% sensitivity level.

 

Assessment

Primary or presumptive diagnosis: Ankle Pain

Differential Diagnoses

 

             Ankle Fracture: An ankle fracture would produce swelling around the injured bone with possible bone deformity and difficulty bearing weight. Patients with ankle fractures often hear a crack or pop noise when an injury occurs. S.J, exhibits these symptoms, but there is no bony deformity noted on physical examination (Dains et al., 2019)

 

             Achilles Tendinitis: Achilles tendinopathy is a soft tissue disorder that causes pain, swelling, and stiffness. Achilles tendonitis is caused by physical activity that involves running and jumping. S.J, displays the symptoms of pain and swelling but did not describe her ankle as being stiff (Mendes & Palmer, 2016).

 

            Anterior ankle Impingement: This is a chronic condition of the bony anterior ankle. This disorder is frequently seen in people involved in sports. It is linked with individuals with recurrent ankle trauma or injury. An affected person will exhibit tenderness, lateral peroneus tertius, and pain with dorsiflexion. There is a possibility that S.J, is experiencing this issue (Tausen et al., 2014).

 

Ankle Sprain: this happens because of an inversion force to the foot, leading to stress in the ankle by stretching and tearing the anterior talofibular ligament or calcaneofibular ligament. Sprains cause minimal to moderate pain, increasing 1 to 2 days after the trauma. When the sprains involve injury to ligamentous structures inflammatory process begins. The symptoms of ankle sprain include swelling, pain, joint stiffness, limited range of motion, and ecchymosis after a few days. Treatment for ankle sprain would involve periods of rest and ice compression. The diagnosis of an Ankle Sprain is very likely since all the symptoms are exhibited (Miklovic et al., 2018).

 

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. 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.

Mendes, A., & Palmer, S. (2016). A look at assessing achilles tendinopathy in the community. British Journal of Community Nursing,                         21(6), 315-316. Retrieved from https://doiorg.ezp.waldenulibrary.org/10.12968/bjcn.2016.21.6.315

Links to an external site. Links to an external    site.

Miklovic, T. M., Donovan, L., Protzuk, O. A., Kang, M. S., & Feger, M. A. (2018). Acute lateral ankle sprain to chronic ankle instability: a                    pathway of dysfunction. The Physician and sports medicine, 46(1), 116-122.https://doi-org/10.1080/00913847.2018.1409604.

Tausen, P., Toy, J., Perez, J. L., Milewski, M. D., & Reach, Jr, J. S. (2014). Anterior ankle impingement: Diagnosis and treatment. Journal of                the American Academy of Orthopaedic Surgeons, 22(5), 333. Retrieved from                                                                                                          https://doiorg.ezp.waldenulibrary.org/10.5435/JAAOS-22-05-333.

Total Points: 100
Name: NURS_6512_Week_8_Discussion_Rubric

Name: NURS_6512_Week_8_Discussion_Rubric

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