NURS 6512 Assessment of the Musculoskeletal System

NURS 6512 Assessment of the Musculoskeletal System

NURS 6512 Assessment of the Musculoskeletal System

I agree that Osgood-Schlatter is the most appropriate diagnosis. Osgood-Schlatter is known as osteochondritis of the tibial tubercle and is a common cause of knee pain in growing children and young teenagers and is a common cause of anterior knee pain in adolescents. Typically occurring in patients aged 10 to 15 years old, and is more common in males. Osgood Schlatter’s disease is usually unilateral, affecting only one knee, but pain can be seen in the knees bilaterally. With Osgood Schlatter disease, multiple minor avulsion fractures occur where the patellar ligament pulls away tiny pieces of the bone.

This leads to the growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to active inflammation in the area. As the bone heals and the inflammation settles, the swelling becomes hard and non-tender. A complex, non-tender lump will be permanently present at the tibial tuberosity. Osgood Schlatter’s disease presents with a gradual onset of symptoms, a palpable hard and tender lump at the tibial tuberosity. Pain in the anterior aspect of the knee is exacerbated by physical activity kneeling, jumping, squatting, and especially when walking up and down stairs (Yanagisawa et al., 2014)

The meniscus tear is highly unlikely, given that the symptoms and diagnostic criteria do not align. The meniscus, or the cartilage, is sandwiched between the tibia and the femur. Two key types of pain are associated with a meniscus tear; the first is pain localized to the joint line. A medial meniscus tear pain will occur on the inside of the knee, and a lateral meniscus tear pain will appear on the outside. The other most sensitive sign that you have a meniscus tear is swelling, although swelling may not happen immediately because there’s not a good blood supply to the meniscus. Still, it could develop 12 to 24 hours after your injury. Some evaluations that can be done during the physical exam would be the Thessaly test, Aegis sign, and Steinman test (Bhan, 2020).

References 

Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus. https://doi.org/10.7759/cureus.8590

Yanagisawa, S., Osawa, T., Saito, K., Kobayashi, T., Tajika, T., Yamamoto, A., Iizuka, H., & Takagishi, K. (2014). Assessment of osgood-schlatter disease and the skeletal maturation of the distal attachment of the patellar tendon in preadolescent males. Orthopaedic Journal of Sports Medicine, 2(7), 232596711454208. https://doi.org/10.1177/2325967114542084

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
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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.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assessment of the Musculoskeletal System

Chapter 22, “Lower Extremity Limb Pain”
This chapter outlines how to take a focused history and perform a physical exam to determine the cause of limb pain. It includes a discussion of the most common tests used to assess musculoskeletal disorders.

Chapter 24, “Low Back Pain (Acute)”
The focus of this chapter is the identification of the causes of lower back pain. It includes suggested physical exams and potential diagnoses.

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.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.

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.

Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010

Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002

Patient Information:  T.J., 15 years old,  African American Male

S.

CC  “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”

HPI:

TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and  localized  around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently  comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .

Reports that Aleve makes it tolerable,  but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.

Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.

Allergies:

No known allergies. Denies food , environmental and latex allergies.

PMHx:

Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.

Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.

SocHx: TJ identifies himself as “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons.  TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies.

Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history.

ROS:

GENERAL:  TJ does not have weight loss, denies fever, chills, weakness or fatigue.

HEENT:  Eyes:  Denies blurred or loss vision. Denies double vision. No  yellowsclerae noted.

 Ears, Nose, Throat:  Reports no hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies  palpitations or edema.

RESPIRATORY:  Denies  shortness of breath, cough or sputum production.

GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood.

GENITOURINARY:  Reports No Burning on urination.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control.

MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee.

HEMATOLOGIC: reports no anemia, bleeding or bruising.

LYMPHATICS: denies enlarged nodes and  history of splenectomy.

PSYCHIATRIC: reports no depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’

Diagnostic tests:

CT scan, MRI, and Xray.

Blood Tests:

CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor)  

Differential Diagnoses

1. Patellofemoral Pain Syndrome .The  main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019).
2. Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019).
3. Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019).
4.  Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019).
5. Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018).

References

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family

                    physician, 99(2), 88–94.

https://pubmed.ncbi.nlm.nih.gov/30633480/

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.

ten Thije, J. H., &Frima, A. J. (2019). Patellar dislocation and osteochondral fractures. The Netherlands journal of surgery, 38(5), 150–154.

https://pubmed.ncbi.nlm.nih.gov/3774187/

Dains, J. E., Baumann, L. C., &Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Habusta, S., Coffey. R, Ponnarasu S, et al.(2022) Chondromalacia Patella.  

         Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/

Vaishya R, Azizi A, Agarwal A, et al.(2018) Apophysitis of the Tibial Tuberosity  

          doi:10.7759/cureus.780

S.

CC (chief complaint): “Lower back pain.”

HPI: D.T. is a 42-year-old Caucasian male with a chief complaint of lower back pain. He reports that the lower back pain began a month ago. He describes the pain as ‘stabbing’ and often radiates to his left leg. He reports that the pain sometimes causes numbness and weakness in the left leg. The low back pain is constant but worsens with activity, prolonged sitting, and bending. The patient has used OTC analgesic creams and Tylenol, which relieve the pain to some degree but recurs after some hours. He is concerned that the back pain may be long-term since it has already lasted a month. This will significantly interfere with his daily work activities. He rates the pain at 5/10.

Current Medications: OTC Diclofenac cream, applies twice daily. OTC Tylenol 500 mg TDS.

Allergies: Allergic to nuts- causes skin itching, redness, and swelling. No drug allergies.

PMHx: The patient has no history of chronic illnesses or admission. His immunization is not up to date. The last Flu shot was more than three years ago. Last TT- July 2018. He has received both Pfizer COVID-19 shots.

Soc Hx: D.T. is a lab technologist with a degree in Analytical chemistry. He is married and lives with his wife and two children, 15 and 10 years old. His hobbies include playing baseball and fishing. He is the captain of the baseball team in his organization. He denies smoking tobacco but reports taking a few whiskey glasses on weekends to wind up. He also denies any past or current substance use. The patient states that he is generally physically fit since he attends baseball practice 2-3 times a week. In addition, he eats balanced meals with a high composition of proteins and vegetables. He sleeps 5-6 hours a day. D.T. has private health insurance cover that also covers his family and is provided by his employer.

Fam Hx: The patient’s paternal grandfather died from prostate cancer at 82 years. His paternal grandmother died from an RTA at 85 years. His father has a history of high blood pressure. His younger brother has chronic asthma. The patient’s children have no chronic illnesses.

ROS:

GENERAL:  He denies fever, weight changes, or generalized body weakness.

HEENT:  Eyes:  Denies eye pain, excessive tearing, or blurred vision. Ears: Denies changes in hearing or ear pain. Nose: Denies nasal discharge, sneezing, or nose bleeds. Throat: Denies throat pain or hoarseness.  

SKIN:  Negative for skin rash, discoloration, or bruises.

CARDIOVASCULAR:  Negative for palpitations, chest tightness, swelling of lower limbs, or SOB on activity.

RESPIRATORY:  He denies difficulties in breathing, cough, wheezing, or sputum.

GASTROINTESTINAL:  He denies abdominal distress or changes in bowels.

GENITOURINARY:  Denies urinary symptoms of penile discharge. 

NEUROLOGICAL: Reports numbness and weakness in the left leg. Denies dizziness or loss of consciousness.

MUSCULOSKELETAL:  Reports lower back pain and left leg pain. Limited ROM on the left leg because of pain.

HEMATOLOGIC:  He denies bruising or a history of anemia.

LYMPHATICS:  Denies swelling of lymph nodes.

PSYCHIATRIC:  Reports increased stress due to prolonged back pain.

ENDOCRINOLOGIC:  Denies excessive sweating, heat and cold intolerance, excessive thirst or hunger, or increased urination.

ALLERGIES:  Hives when he eats nuts.

O.

Physical exam:

Vital Signs: BP- 122/78; HR- 86; RR-16; Temp-98.4; SPO2- 100%; HT-5’5; WT-167; BMI-27.8

GENERAL: White male patient in his 40s. The patient is calm and in no distress. He is well-groomed and appropriately dressed in casual wear. He exhibits positive facial expressions and body language. His speech is clear and goal-directed, with normal volume and rate.

CARDIOVASCULAR: Regular heart rate and rhythm.S1 and S2 are heard on auscultation. No gallop sounds or murmurs were heard.

RESPIRATORY: Smooth and even respirations. Symmetrical chest wall expansion. Lungs clear bilaterally.

NEUROLOGICAL: CN II – XII are intact; DTRs 2+ on the right leg and 1+ on the left leg. Normal sensation in the right foot; Reduced sensation in the left foot. Muscle strength 5/5 (right lower limb) 3/5 (left lower limb)

MUSCULOSKELETAL: Torso and head are upright. Normal balance when walking and standing, and the arms swing freely at the side. Straight leg raising elicits pain that radiates down the left leg when the left leg is slowly raised above 60°. On raising the right leg, the patient reports pain radiating down the left leg to the foot. ROM 4/5 in the left leg. Back ROM elicited pain with lateral rotation, forward flexion, and spine hyperextension.

Diagnostic results: Spine X-ray: Abnormal spine curve.

A.

Differential Diagnoses

Sciatica: Sciatica is characterized by pain along the sciatic nerve caused by compression of lumbar nerve roots in the lower back. Clinical features of sciatica include unilateral leg pain greater than low back pain; Pain radiating to the foot or toes; Numbness and paresthesia in the same distribution; Straight leg raising test elicits more leg pain; Localized neurology limited to one nerve root (Stynes et al., 2018). This is the most likely diagnosis due to positive symptoms of low back pain radiating to the left leg, numbness on the left foot, straight leg testing producing pain on the left foot, and crossed straight leg raising eliciting pain on the left foot.

Herniated lumbosacral disc: This is characterized by low back pain, limited trunk flexion, and sensory abnormalities at the lumbosacral nerve root distribution (Yu et al., 2022). The patient has low back pain, back pain with forward flexion, and an abnormal spine curve making Herniated lumbosacral disc a differential diagnosis.

Spinal nerve root impingement: This occurs when a spinal nerve root is compressed or irritated. The compression often causes high discomfort, like loss of sensation and weakness. When nerve root impingement occurs, the parts of the body that lie along the nerve’s path are usually the most severely affected (Berry et al., 2019). Compression of a spinal nerve root may have caused low back pain, left leg pain, and weakness. Besides, the abnormal spine curve may have irritated a nerve root.

Lumbar Spondylolisthesis: Lumbar Spondylolisthesisis characterized by intermittent and localized low back pain triggered by flexing and extending the affected segment (Dunn, 2019). The patient has low back pain and back pain with lateral rotation, forward flexion, and spine hyperextension, which are consistent with Spondylolisthesis.

Lower Back Muscle Spasm: Spasm of the lower back muscle is believed to produce secondary low-back pain and tenderness (Urits et al., 2019). This can be the cause of the patient’s lower back pain.

P.  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus, 11(10), e5934. https://doi.org/10.7759/cureus.5934

Dunn, B. (2019). Lumbar spondylolysis and Spondylolisthesis. Journal of the American Academy of PAs, 32(12), 50–51. DOI: 10.1097/01.JAA.0000604892.88852.c6

Stynes, S., Konstantinou, K., Ogollah, R., Hay, E. M., & Dunn, K. M. (2018). Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PloS one, 13(4), e0191852. https://doi.org/10.1371/journal.pone.019185

Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., Viswanath, O., Jones, M. R., Sidransky, M. A., Spektor, B., & Kaye, A. D. (2019). Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Current pain and headache reports, 23(3), 23. https://doi.org/10.1007/s11916-019-0757-1

Yu, P., Mao, F., Chen, J., Ma, X., Dai, Y., Liu, G., … & Liu, J. (2022). Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis Research & Therapy, 24(1), 1-18. https://doi.org/10.1186/s13075-022-02894-8