Assessing Musculoskeletal Pain
Manage Discussion Entry for Discussions on Assessing Musculoskeletal Pain in Patients.
HPI: J. H. is a 15-year-old Caucasian male brought to the clinic by his mother to evaluate bilateral knee pain x 1 week. The patient describes the pain as dull and reports a clicking and catching sensation under the patella. Pain rated as an 8 out of 10 on the intensity scale. Pain worsens with physical activity. The pain improves with rest and NSAIDs. The patient denies injury or trauma to bilateral knees. The patient denies radiation.
Current Medications: Ibuprofen 200mg 2 tablets PRN pain, last dose yesterday at 7 pm
Allergies: Denies allergies to medications, latex, food, or environmental factors.
PMHx: Denies medical history. Denies hospitalization. Denies surgical history. All immunizations are up to date. Last tetanus- 2 years ago. Last influenza vaccine- 10/10/2022
Soc Hx: In the 9th grade, enjoys high school. Plays football and baseball in high school. Lives with his father, mother, and younger sister and reports feeling safe at home. Denies tobacco, alcohol, or illicit drug use. Denies exposure to secondhand smoke.
· Father- Type 2 diabetes
· Mother- Hypertension
· Sister- Healthy
· Paternal Grandfather- Type 2 diabetes, Hypertension
· Paternal Grandmother- Hyperlipidemia
· Maternal Grandfather- Hypertension
· Maternal Grandmother- Hypertension
ROS: cover all body systems that may help you include or rule out a differential diagnosis. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: Denies fever, chills, unintentional weight loss or gain, or loss of appetite.
SKIN: Denies rashes, lesions, or moles.
CARDIOVASCULAR: Denies chest pain or chest tightness. Denies palpitations or irregularities in rhythm. Denies peripheral edema or orthopnea.
RESPIRATORY: Denies shortness of breath, dyspnea on exertion, or hemoptysis. Denies cough, wheezing, history of asthma, or inhaler use.
MUSCULOSKELETAL: Reports bilateral knee pain x 1 week. Describes pain as dull, rated 8/10 on the intensity scale. Pain worsens with physical activity and improves with rest and NSAIDs. Denies radiation. Denies injury or trauma to knees. Denies swelling, ecchymosis, or erythema.
Assessing Musculoskeletal Pain Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format, i.e., General: Head: EENT: etc.
VITAL SIGNS: Blood Pressure: 115/70, Pulse 82, RR 16, Oxygen Saturation 99% on room air, Temperature 98.3F orally, Height 6’0”, Weight 115lbs.
GENERAL: Patient alert and oriented to person, place, and time. Cooperative and answers questions appropriately. Well-developed and well-nourished.
SKIN: Intact, no lesions or rashes. Skin turgor is good. No pallor, jaundice, or cyanosis present.
CARDIOVASCULAR: Heart rate and rhythm regular, S1 and S2 audible. No gallops, murmurs, valve clicks, or friction rub auscultated. No peripheral edema is present.
RESPIRATORY: Chest wall expansion and diaphragmatic excursion symmetrical. No rashes, lesions, accessory muscle use, or ecchymosis present. Breath sounds are present and clear in all anterior and posterior lung fields, and no adventitious sounds are present. Tactile fremitus symmetric bilaterally, no crepitus palpated. Negative bronchoscopy. All areas are resonant on percussion.
MUSCULOSKELETAL: No swelling, edema, ecchymosis, or erythema present on bilateral knee inspection. Tenderness was reported when the bilateral knee was palpated. Right knee- Flexion 5/5, painful, Extension 5/5, painful. Negative Lachman sign. Left knee- Flexion 5/5, painful; Extension 5/5, painful. Negative Lachman sign. Full ROM in all extremities.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
· Bilateral knee X-RAY
· CBC- rule out infection
· Uric acid- Rule out gout
· CT scan if XRAY negative for acute processes
Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.
1. Osgood Schlatter Disease
The primary diagnosis for this patient is Osgood Schlatter’s Disease (OSD). OSD is a non-traumatic knee problem in sports-active children aged 8-15 (Leeuwen et al., 2022). OSD is characterized by knee pain and tenderness at the tibial tuberosity that worsens during physical activity (Leeuwen et al., 2022).
Patellar tendinopathy occurs due to chronic, repative tendon overload (Aicale et al., 2020). Patients often complain of anterior knee pain and cannot participate in physical activity due to pain (Aicale et al., 2020). This patient has full ROM in bilateral knees and can participate in physical activity, excluding this diagnosis as the primary diagnosis.
Bursitis and gout are listed as differential diagnoses but are not the primary diagnosis for this patient. Bursitis is inflammation of the bursa causing limited ROM, pain with movement, and an erythematous, warm site (Ball et al., 2019). Gout occurs due to elevated uric acid levels causing a sudden onset of a hot, swollen joint (Ball et al., 2019). This patient did not have signs or symptoms of bursitis or gout, excluding this diagnosis.
A fracture occurs when there is a partial or complete break in the continuity of bone (Ball et al., 2019). Fractures are normally unilateral and occur due to trauma. This patient denies trauma or injury to the area, excluding this diagnosis.
Aicale, R., Oliviero, A., & Maffulli, N. (2020). Management of Achilles and patellar tendinopathy: what we know and can do. Journal of Foot and Ankle Research, 13(59). https://doi.org/10.1186/s13047-020-00418-8.
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.
Leeuwen, G., Schnepper, E., Rathleff, m., bindels, P., Bierma-Zeinstra, S., & Middelkoop, M. (2022). Incidence and Management of Osgood Schlatter Disease in general practice: Retrospective cohort study. British Journal of General Practice, 72(717), 301-306. https://doi.org/10.3399/BJGP.2021.0386.
Episodic/Focused SOAP Note Template
Initials: J.L. Age: 46 years Sex: Female Race: Asian
CC (chief complaint): “I have pain in my ankles, but I am more concerned about my right ankle.”
Onset: 3 days ago
Character: the patient is feeling some dull and generalized pain in her ankle. She also reports feeling some pumping sensation.
Associated signs and symptoms: patient reports that she felt some pop sound during the injury. She also reports that her right ankle is swollen and bruised.
Timing: she reports that pain is continuous.
Exacerbating/ relieving factors: she reports pain when she bears some weight on it.
Severity: 4/10 pain scale
Current Medications: The patient reports taking some ibuprofen 500 mg thrice daily, but the pain has not completely subsided. The patient denies having any prescription medication.
Allergies: patient denies food, animal, latex, or medication allergies.
PMHx: patient denies chronic conditions or surgeries. Soc Hx: The patient works as a middle school teacher and loves to play soccer. She reports that she got injured playing soccer. The patient denied smoking, drinking alcohol or using illicit drugs. The patient also reports that she is a Christian and lives with her husband.
Mother: hypertension and osteoporosis.
Father: type 2 diabetes
Paternal grandfather: type 2 diabetes
Paternal grandmother: breast cancer
Maternal grandfather: healthy
Maternal grandmother: osteoporosis, type 2 diabetes, and hypertension.
GENERAL: patient denies fever, fatigue, night sweats or chills.
CARDIOVASCULAR: Patient denies chest pain, irregular heartbeat, or edema.
RESPIRATORY: patient denies shortness of breath, coughing or sputum.
MUSCULOSKELETAL: patient denies muscle, back or bone pain. The patient reports having ankle joint pain in both ankles but more pain in the right ankle.
VS: HR: 89 BP: 122/82 Temp: 37.1 C RR: 22 SpO2: 98% Height: 5’7” Weight: 166 lbs. BMI: 26.0, Healthy normal weight.
General: patient appears to be healthy but is limping.
Cardiovascular: S1 and S2 heart sounds are present. Regular heartbeat noted.
Respiratory: clear breathing sounds are present in all anterior and posterior chest areas.
Musculoskeletal: Full ROM in all joints except right ankle. Right ankle is swollen and bruised, 3/5 ROM and 2/5 ankle strength.
Diagnostic results: ankle x-ray.
Assessing Musculoskeletal Pain Differential Diagnoses
A sprained ankle is the most likely diagnosis, as the patient reports experiencing pain that started when she was playing soccer. She reports symptoms that are consistent with those of a sprained ankle. For example, she reports hearing a pop sound and ankle pain and can bear some weight on the ankle. While the condition can cause pain, swelling, tenderness, and bruising, it is less likely to affect the patient’s ability to bear weight on foot (Tran & McCormack, 2020).
Fractured ankle- the patient presents with some symptoms consistent with a fractured ankle. The patient reports swelling, pain, and a pop sound, which can be present in a fractured ankle. This condition was, however, eliminated as patients with the condition are often unable to bear any weight on foot, which is unlike the patient (Gougoulias et al., 2020).
Ankle dislocation- happens when the ankle bones no longer meet properly. Patients will report experiencing sudden pain, swelling, and bruising. The injury is common among sports people as the patient. The condition was eliminated as the patient can bear weight on her ankle, which is impossible for patients with dislocations (Chi et al., 2021).
Achilles tendinitis- a condition caused by injury to the Achilles from overuse. Patients often report experiencing pain at the back of the leg and, at times, near the ankle. The condition was eliminated as it is progressive and may cause stiffness and tenderness (Park et al., 2020). Additionally, the condition does not cause popping sounds.
Subtalar Joint Sprain can cause patients to experience ankle pain, swelling, bruising, and joint instability (Wang et al., 2022). This condition was eliminated as the patient does not report that her ankle feels loose or wobbly.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Chi, Y. L., Gao, X., Xu, Y. J., Bu, X. M., Han, L., Zhang, X., Gao, L. F., Tian, R. H., Wang, H. B., & Wu, B. (2021). Open total dislocation of ankle joint without fractures: A case report. Medicine, 100(22), e26247. https://doi.org/10.1097/MD.0000000000026247
Gougoulias, N., Oshba, H., Dimitroulias, A., Sakellariou, A., & Wee, A. (2020). Ankle fractures in diabetic patients. EFORT open reviews, 5(8), 457–463. https://doi.org/10.1302/2058-5241.5.200025.
Park, S. H., Lee, H. S., Young, K. W., & Seo, S. G. (2020). Treatment of Acute Achilles Tendon Rupture. Clinics in orthopedic surgery, 12(1), 1–8. https://doi.org/10.4055/cios.2020.12.1.1
Tran, K., & McCormack, S. (2020). Exercise for treating Ankle Sprain: A Review of Clinical Effectiveness and Guidelines. Canadian Agency for Drugs and Technologies in Health.
Wang, S., Liu, P., Chen, K., Zhang, H., & Yu, J. (2022). Mouse model of subtalar post-traumatic osteoarthritis caused by subtalar joint instability. Journal of orthopedic surgery and Research, 17(1), 537. https://doi.org/10.1186/s13018-022-03435-4