Discussion About Assessing Musculoskeletal Pain

Discussion About Assessing Musculoskeletal Pain

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SUBJECTIVE DATA

CHIEF COMPLAINT (CC):  “I have been experiencing lower back pain, which sometimes radiates to the back.”

HISTORY OF PRESENT ILLNESS (HPI): The client is a 42yo male who presented to the clinic with lower back pain, which started last month. The client added that the pain sometimes radiates to his left leg Discussion About Assessing Musculoskeletal Pain.

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PAST CHILDHOOD ILLNESSES: No childhood illness.

PAST MEDICAL HISTORY (PMH): No history of chronic illnesses.

PAST SURGICAL HISTORY (PSH): Denies surgeries.

ALLERGIES: No known drug or food allergy.

IMMUNIZATION STATUS: Childhood immunizations are up to date.

SOCIAL HISTORY: Married to one wife. He has two kids, a 12yo son, and an 8yo daughter.

SEXUAL HISTORY: He is heterosexual and reports being sexually active.

MEDICATIONS: No current medication.

ROS:

General: The client denies fever or weakness.

Skin Denies skin rashes or cracking.

HEENT: Denies head injury, blurred vision, hearing difficulty, nasal blockage, or swallowing difficulty.

Respiratory: Denies breathing difficulty.

Cardiovascular: Denies chest tightness or pressure.

Gastrointestinal: Denies constipation.

Genitourinary: Denies frequent urination.

Peripheral Vascular: Denies numbness.

Musculoskeletal: Reports pain in the lower back, which sometimes radiates to the back Discussion About Assessing Musculoskeletal Pain.

Neurologic: Denies numbness.

Hematologic: Denies bleeding.

Endocrine: Denies intolerance to heat or cold.

Psychiatric: Denies anxiety or suicidal thoughts.

OBJECTIVE DATA

Physical Exam

Vital signs: HR-91 bpm, Temp-97.9*F, B/P-118/65, RR-18, Pulse Ox-97%, Weight – 196lbs, Height – 5’8″, and BMI 29.8.

General: The client is a 42yo male. He is well-developed and appropriately dressed. The client is attentive during the interview and responds to all interview questions appropriately. His affect and judgment are good. He seems to be in mild distress.

HEENT: No deformities to the scalp. Pupils are sensitive to light. No nasal discharge. Ears have clear conjunctiva. No swelling in the throat Discussion About Assessing Musculoskeletal Pain.

Respiratory: No wheezing sound.

Cardiovascular: Regular heartbeats and rhythm.

Gastrointestinal: Non-tender abdomen.

Genitourinary: N/A.

Musculoskeletal: No edema                                                                                                                                                                                                    Neurological: No gait.

Psych: No anxiousness or agitation.

ASSESSMENT:

Differential Diagnosis

The differential diagnosis for this client starting with the most likely diagnosis are as follows; Discussion About Assessing Musculoskeletal Pain

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1. Low back pain – Primary diagnosis
2. Sciatica

• Lumbar Spinal stenosis

Low back pain: This condition qualifies as the primary diagnosis for this client. It is characterized by numbness and tingling pain in the lower back, which might spread to one or both lower extremities (Foster et al., 2018). Similarly, the client reports pain in the lower back that sometimes radiates to the left leg.

Sciatica: This condition is characterized by pain in the lower back, buttock, and leg. Other symptoms associated with this condition include numbness or weakness in the lower back, buttock, feet, or less (Jensen et al., 2019). Additionally, the pain worsens with movement. The client might have this condition since he reports pain that sometimes radiates to the back. Nonetheless, this condition is ruled out since some significant symptoms, including numbness and weakness, are negative.

Lumbar spinal stenosis: People with this condition report numbness, weakness, or tingling in extremities, including arms, hands, legs, or feet (Jensen et al., 2021)Discussion About Assessing Musculoskeletal Pain. The client might have this disorder since he reported pain in the left leg. However, spinal stenosis is ruled out since it is not characterized by lower back pain, which is the client’s chief complaint.

References

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … & Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383. DOI: https://doi.org/10.1016/S0140-6736(18)30489-6

Jensen, R, K et al. (2019). Diagnosis and treatment of sciatica. BMJ; 367. Doi: https://doi.org/10.1136/bmj.l6273.

Jensen, R, K et al. (2021). Lumbar spinal stenosis. BMJ; 373:n1581. Doi: https://doi.org/10.1136/bmj.n1581.

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: Discussion About Assessing Musculoskeletal Pain

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: Discussion About Assessing Musculoskeletal Pain

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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?

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 Discussion About Assessing Musculoskeletal Pain