Assessing Musculoskeletal Pain Essay Example

Assessing Musculoskeletal Pain Essay Example

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. Assessing Musculoskeletal Pain  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.

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.

Below is the case study to use for reply:
Week 8 Discussion
COLLAPSE
Focused Soap Note for Back Pain Week 8

Assessment

 

Subject:

Chief Complaint: ‘pain in my lower back and down my LEFT leg.”

HPI: Mr. E.U is a 42-year-old African American who reports LBP, which began one month ago. He reports no history of trauma or apparent injury. He reports using Acetaminophen and ibuprofen, which provided mild pain relief. He reports to be a bricklayer who has experienced LBP throughout the years. He reports that he has always ignored the ache and the burning sensation radiating from his left buttocks down to the left lateral leg to his foot. Reports numbness and a tingling sensation. He reports that he had always ignored the pain till one week ago when the normal ache he had been feeling over the years intensified. He rates this pain at eight out of ten. He reports that the pain is more intense when he bends at the waist. He explains the job has generally affected his job and his family.

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Current Medications

Acetaminophen 500 PO for three days

Ibuprofen 200mg PRN pain

PMH

No history of hospitalization.

No history of surgery.

No history of blood transfusion

No history of chronic illness

The patient reports that all immunizations are up to date.

Allergies: No food or drug allergy

Social History: the patient has been a self-employed bricklayer for over twenty-five years. He is a divorcee who lives alone. He co-parents with his wife to raise their two daughters. He does not smoke or drink alcohol. He reports that his current state affects the quality of his job and his family. he is a staunch catholic Christian.

Family History: all parents are alive. The father has diabetes. All his two children are alive and well.

ROS

General: patient appears to be in distress and denies fever, fatigue, night sweat, and chills

HEENT: Denies blurred vision, double vision, eye pain, ear pain, and sore throat.

Cardiovascular: denies chest pain, edema, palpitations, syncope, orthopnea

Respiratory: denies coughing, difficulty in breathing, abnormal chest sounds, and chest tightness

Gastrointestinal: denies abdominal pain, vomiting, nausea, heartburn, blood in stool, and change in appetite

Genitourinary: patient denies difficulty in passing urine, patient denies foul-smelling and cloudy urine,

denies flank pain denies, hematuria, and urine color change.

Musculoskeletal: reports radiating pain to the left leg, reports lower back pain, reports increased pain with forwarding flexion and bending at the waist, and reports back pain over the years. Denies injury, fall, and trauma.

Neurological: reports numbness and tingling sensation, denies foot drop, denies headache, denies ataxia.

Psychiatric: reports increased stress as a result of pain that affects his job and family life, denies anxiety attacks, and has a history of depression and the urge to abuse drugs.

Objective

Vital Signs: BP 153/81 HR 78 RR 18 SPO2 99% HT 5’11’ BM1 25%

General: alert, make good eye contact, appears tired, able to communicate,

HEENT: Normocephalic, no sinus pain, no sinus tenderness, PERRLA, nares patent and pink, no lesions

Respiratory: clear breath sounds, normal chest expansion, normal resonance on percussion

 

Cardiovascular: capillary refill less than three seconds, no murmur, no gallops, no heaves, no thrills, normal S1, and S2. No edema no abdominal bruit.

Gastrointestinal: reported sight tenderness upon gentle palpation in the symphysis pubis.

Musculoskeletal: upright posture, steady gait, strong muscular build, legs are of equal length, no swelling, no deformities, no pain. No redness on the joints. Musculoskeletal Pain  The positive Lasegue  at 45 degrees, positive Bragards test increases with internal rotation.

Forward flexion and pelvic tilt cause increased pain and radiculopathy. FABER assessment is limited as a result of back pain. No muscle atrophy, positive left hamstring tightness that is greater than the right.

Neurological: no twitching, no tremors,

Psychiatric: cooperative, positive demeanor, maintains eye contact, clear speech.

Diagnostics

MRI of the lumbar and the sacral region. This is because the client has experienced the pain for over a month. He has also felt a tingling and a burning sensation down his left leg for over three years. His condition is now getting worse, and the patient is presenting with neurological deficits. The most definitive test that can be used to rule out a disc herniation would be an MRI (Alonzo et al., 2018).

Flat Lumbar Sacral Radiograph- if restrictions occur as a result of insurance, this test can do. As a result of the demands that accompany his job, a tumor, fracture, or degenerative changes can be identified.

ESR & ALP- The levels of ESR and ALP will get back to normal if the back pain is a result of osteoarthritis (Alonzo et al., 2018). It may also be from a mechanical injury or be elevated with multiple myelomas ankylosing spondylitis, and infectious spinal. On the other hand, an elevation of Alkaline phosphates may be as a result of Paget’s disease (Alonzo et al., 2018).

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Differential Diagnosis:

Herniated Disc with spinal compression at the L5, S1 level with radiculopathy. The History of pain and a burning sensation can be from a bulging disc with symptoms that are worsening and no history of trauma or a recent injury (Alonzo et al., 2018).There is a dermatomal pattern of pain and burning sensation which radiates from the buttocks down to the foot. There is also a decreased dull sensation on the mid-calf to the toe; there is increased pain and decreased strength with dorsiflexion and plantarflexion. There is also increased pain with various tests. The SLR, the Braggard’s test, spinal flexion, and pronation. Slight spinal flexion, such as putting on boots, causes pain (Alonzo et al., 2018).

Spinal stenosis at L5 and S1 levels with radiculopathy this condition is more common among adults over the age of 50 years (Isu et al., 2018). However, with the type of work the patient does, he is at a higher risk. Therefore, there is a likelihood of early changes of degeneration. The diagnosis may be difficult to differentiate because of the nature of his job and the different positions he assumes. However, the patient does not report any pain or complain of hyperextension and spinal flexion. It is difficult to ascertain the claudication type lower leg increases or decreases. Without an MRI, the patient may be required to journal his symptoms and closely assess them (Isu et al., 2018).

Bulging Disc L5, S1 with Sciatica the History of the patient fits with this diagnosis. There is the History of repetitive strenuous activity and a dermatomal pattern. An aggressive chiropractic care could be considered. Physical therapy and conservative treatment should also be considered (Varveris , 2019). However, with the changing pain status, it is essential to check the MRI results first (Isu et al., 2018).

Osteomyelitis- A positive SLR test is indicative of this condition. There is no recent invasive testing, for example, a bone marrow aspiration. It is unlikely. However, caution is generally errored by drawing of the lab tests (Grinnell et al., 2020). Therefore, it is essential that it should be ruled out.

Psychological back pain- considering the patient is divorced and that the pain is affecting his family and job, the patient might be experiencing psychological back pain which exacerbates the acute pain to chronic (Urits et al., 2019). However, it can be unlikely since the patient lives a healthy life and has no history of drug abuse, anxiety, or depression.

Assessing Musculoskeletal Pain Essay Example

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