NURS 6512 Week 8: Assessment of the Musculoskeletal System

NURS 6512 Week 8: Assessment of the Musculoskeletal System

NURS 6512 Week 8: Assessment of the Musculoskeletal System

Week 8: Assessment of the Musculoskeletal System

Patient Information:

JD, 15, M, Caucasian

S.

CC: JD complains of dull pain in both knees

HPI: JD is a 15-year-old Caucasian male presents with dull pain in both knees bilaterally and occasional catching/clicking with ambulation. JD reports the pain started 3 weeks ago after he collided with a runner at home plate during a baseball game. JD reports the pain as dull and intermittent on a scale of 5/10. He has not taken anything for the pain at this point. Walking and physical activity make the pain worse and ice/elevation and resting the legs make the pain better. JD reports he has not been able to participate in his baseball games since the injury occurred.

Current Medications: no current medications

Allergies: NKDA, no environmental allergies, no food allergies

PMHx: No previous medical history or surgeries

Soc Hx: Denies the use of cigarettes, denies etoh use, denies use of marijuana and illicit drugs. Freshman in high school, drum major in the band and plays basketball and baseball.

Fam Hx: Mother is 38 y/o with hypertension, Father is 35 with diabetes, Maternal grandmother is living with hypertension and hyperlipidemia, Maternal grandfather is living with hypertension and BPH, Paternal grandmother is living with diabetes and hypertension, Paternal grandfather is living with hyperlipidemia, Sister is 7 years old with no medical issues.

ROS:

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat . Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

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

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No burning on urination and denies urgency.

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

MUSCULOSKELETAL:  Reports clicking/catching sensation under bilateral knee caps during ambulation

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

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

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

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O.

General: JD presents alert and oriented, appropriate hygiene, and without gait disturbances

Cardio: S1/S2, no murmurs or adventitious heart sounds heard

Resp: Lung sounds clear throughout lobes bases bilaterally, respirations even and unlabored

Musculoskeletal: Popping sounds heard with flexion of knees bilaterally, ballottement positive bilaterally.

Diagnostic results: Xray of bilateral knees, MRI of knees bilaterally

A.

Differential Diagnoses:

Bursitis: Bursitis is common in individuals who are often in the kneeling or squatting position. The prolonged kneeling causes inflammation of the bursa sac. This patient is a catcher on his baseball team and is squatting for extended periods of time (LeManac et al., 2012). Bursitis presents as pain and swelling in the knee joints exacerbated by the kneeling position.

ACL tear: Due to this patient being active in sports he could have torn his ACL. An ACL tear can present with symptoms such as popping, pain, swelling, and discomfort while walking. ACL tears can happen with a sudden change in directions, quickly slowing down, jumping, and landing wrong (Orthoinfo, 2014).

Patellar Tendonitis: This is reported as pain at the tendon where the patella connects to the tibia. This is common in individuals who participate in jumping activities such as basketball and volleyball players. Also known as “jumper’s knee”. This is caused by tiny tears to the patella tendon from increased stress over time causing weakness and pain to the affected area (Mayo Clinic, 2019). This patient plays basketball in high school and is very active and has high probability of this injury

Patellar fracture: This injury can take place due to blunt force to the affected area. The patient could have fallen on the basketball court or been hit by another player during a baseball game causing trauma to the knee. This presents with the inability to walk or straighten the leg. Severe pain or swelling and oftentimes bruising to the area (Boston Medical Center, n.d.).

Meniscus tear: The meniscus is cartilage that absorbs the impact of fast movements and the shock of body movements. The cartilage can tear with sudden movements or changing of directions. This patient participates in sports that could cause injuries such as this especially basketball. Meniscus injuries present with pain, swelling, locking/catching at the knee joint (John Hopkins Medicine, n.d.).

References

Anterior cruciate Ligament (acl) injuries – OrthoInfo – AAOS. OrthoInfo. (2014). https://orthoinfo.aaos.org/en/diseases–conditions/anterior-cruciate-ligament-acl-injuries/.

Le Manac, h, A. P., Ha, C., Descatha, A., Imbernon, E., & Roquelaure, Y. (2012). Prevalence of knee bursitis in the workforce. Occupational Medicine, 62(8), 658–660. https://doi-org.ezp.waldenulibrary.org/10.1093/occmed/kqs113

Mayo Foundation for Medical Education and Research. (2019, October 16). Patellar tendinitis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/patellar-tendinitis/symptoms-causes/syc-20376113.

Patellar (Kneecap) Fracture. Boston Medical Center. (n.d.). https://www.bmc.org/patient-care/conditions-we-treat/db/patellar-kneecap-fracture.

Torn meniscus. Johns Hopkins Medicine. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/torn-meniscus.

Week 8: Assessment of the Musculoskeletal System

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

Photo Credit: SCIEPRO/Science Photo Library/Getty Images

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Learning Resources-Week 8: Assessment of the Musculoskeletal System

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

• • Review of Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

• Chapter 21, “Musculoskeletal System” (pp. 501-543)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. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

• • Chapter 22, “Limb Pain” (pp. 356-374)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)” (pp. 288-300)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”; p. 29)

• Chapter 4, “Pediatric Preventative Care Visits” (“Documentation of Important Components of Age Specific Physical Exams and Sports Pediatric Sports Participation Physical Exam”; pp. 106-107)

Note: Download this Adult Examination Checklist and Physical Exam Summary: Abdomen to use during your practice musculoskeletal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Adult Examination Checklist: Guide for Musculoskeletal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Musculoskeletal system. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. This Musculoskeletal System Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

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. Retrieved from the Walden Library databases. 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.

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on skeletal trauma in musculoskeletal radiology.

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 Retrieved from the Walden Library Databases.

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. Retrieved from the Walden Library Databases.

Required Media – Week 8: Assessment of the Musculoskeletal System

Online media for Seidel’s Guide to Physical Examination

In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Optional Resources FOR Week 8: Assessment of the Musculoskeletal System

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

• Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.

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NURS 6512 Week 8 Discussion: Assessing Muscoskeletal Pain

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 provide 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.

Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, 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.

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?

Case 2: Ankle Pain

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 Ottowa ankle rules to determine if you need additional testing?

Case 3: Knee Pain

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?

To prepare:

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

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 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.

Patient Information:

K.M. – 46-yearld-old Caucasian female

CASE 2 Ankle Sprain

S.

CC (chief complaint) Bilateral ankle pain with emphasis to right ankle

HPI:

The patient is a 46-year-old causation female presenting with bilateral ankle pain.  She states hearing “a pop” in her right ankle while playing soccer over the weekend (5 days ago), so she is seeking treatment/diagnosis.  The patient felt like her foot became caught in the grass, which caused her to pitch forward; the “pop” sound felt attributed to the top or outside of her ankle.  Current pain is to bilateral ankles with a pain rating of 2 to the left ankle and 6 to the right ankle at the time of injury.  Pain in the right ankle was immediate, and swelling began to occur several hours later.  Her pain is described as a constant throbbing and an overall feeling of instability. 

Pain is worsened when weight is applied during ambulation.  Ice packs were placed on the ankle intermittently to reduce swelling/inflammation, ankelwas also elevated to reduce swelling, and Motrin 400mg PO every 6 hours was taken for pain/inflammation.  These interventions helped to subside swelling and pain mildly but were deemed ineffective.  Pain levels are elevated when bearing weight and attempting to walk.  Two days post-status, the ankle began to show signs of bruising with increased swelling.

Current Medications:

Ibuprofen 400mg PO tablet – taken every 6 hours for pain/swelling (last dose 7am this morning)

Bone Health Supplement PO capsule (Vitamins C, D, K, and magnesium) – 1 capsule daily for (6 years) for bone strengthening and prevention of osteoporosis (last dose this morning).

Allergies:

1. Medications – denies
2. Food – denies
3. Latex – denies
4. Environmental – denies

PMHx: Denies medical history

Soc Hx:

The patient is a local grocery store manager, and her hobbies include playing soccer, hiking, walking, and spending time with family and friends.  She remains active in the winter by swimming at her local gym and walking on the treadmill.  She has been married for 16 years and has a daughter.  Her husband works for an accounting firm and has been there for 20 years.  They utilize the healthcare benefits from her husband’s firm and have never had trouble obtaining healthcare services.  She describes her living environment as safe and frequently walks in the evening with neighbors.  Her diet consists of dark leafy greens, lean proteins such as lean red meat and fish, bananas, apples, water, and mild. 

The patient denies tobacco, alcohol, and illicit drug use.  She takes one supplement daily for bone strengthening and osteoporosis prevention (citing her mom and grandmother had osteoporosis) and OTC medications such as Motrin for her recent ankle injury.  Due to the patient’s history of ankle injuries, education was provided regarding an increased likeliness of such an injury re-occurring; stretching exercises prior to activity and ankle support when participating in physical activities were encouraged.  

Fam Hx:

5. Father – 81yr old (HTN, Hyperlipidemia)
6. Mother – 74yr old (HTN, Hx smoking, osteoprorosis Dementia – lives in a long term care facility)
7. Daughter – 15yr old (No past/current medical history)
8. Husband – 57yr old (Asthma, HTN, Hx smoking – 16 year pack history)
9. Maternal Grandmother – 78yr old HTN, osteoporosis
10. Maternal Grandfather – Passed away 88 years old from heart attack (Hx HTN, hyperlipidemia)
11. Paternal Grandmother – passed away at 86 years of age of natural causes
12. Paternal Grandfather – passed away at 96 years of age of COPD (Hx HTN, tobacco use – 60 year pack history)

Immunizations/Vaccinations History:

13. Influenza Vaccination – annually, last received 10/12/22
14. COVID 19 Vaccination – 2 doses 9/17/21 and 10/27/21 (did not receive vaccination booster)

15. DTaP Vaccination – 5 years ago this month 4/26/18

16. States all vaccinations as child are current and up to date

ROS:

GENERAL:  Patient presents as nervous and is anxious regarding the status of her ankle.

HEENT:  

17. Head – Denies headaches, dizziness, trauma, lightheadedness, syncope.
18. Eyes:  Denies changes/loss of vision, blurriness, pain, drainage, or trauma. Patient denies wearing glasses or contacts.
19. Ears: Denies changes/loss of vision, trauma, discharge, Hx of past ear infection, or pain. Last eye exam was 6 months ago and without significant finding(s).
20. Nose: Denies drainage, trauma, pain, congestion, bloody nose, or sneezing
21. Throat:  Denies sore throat, difficulty swallowing, or sore throat. Patient denies changes to voice, hoarseness, or trauma.

SKIN:  Denies episodes of rashes or itching.

CARDIOVASCULAR:  Denies chest pain, pressure, discomfort, or tightness.  Denies shortness of breath (SOB), unusual/easily bruising, swelling of extremities (aside from current injury, patient denies above signs/symptoms).  Denies problems associated with general/overall circulation.

RESPIRATORY:  Denies SOB, difficulty/pain upon inspiration or expiration. Denies cough and states last TB vaccination was at 35 years or age (voluntary as she works with the public).

GASTROINTESTINAL:  Denies anorexia, changes/loss of appetite, nausea/vomiting, or diarrhea. Denies abdominal pain, blood, or changes to stool

GENITOURINARY:  Denies burning/pain/difficulty on urination. Denies current pregnancy, last menstrual period 3/18/23 and have been regular/consistent.  Last visit to gynecologist 2 months ago with unremarkable findings including Pap smear.

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

MUSCULOSKELETAL:  Denies back pain, joint pain or stiffness aside from site of injury. Pain level at site of injury (R/ankle) is 8 and described as throbbing and constant that radiates up the leg.  Ice and Motrin for inflammation and pain have slight affect to pain/discomfort levels.

HEMATOLOGIC:  Denies Hx bleeding, bruising, or history of anemia.

LYMPHATICS:  Denies enlarged lymph nodes.  Denies Hx of splenectomy.

PSYCHIATRIC:  Denies Hx of depression, anxiety, or mental illness. Denies sleep disturbances, irritability, difficulty concentrating, and reports overall mood as stable.

ENDOCRINOLOGIC:  Denies sweating or intolerance to heat and cold environments/temperatures. cold or heat intolerance. Denies/has not experienced polyuria, polydipsia, excessive thirst/hunger.

ALLERGIES:  Denies allergies to food, medications, latex, or environmental/seasonal. Denies Hx of rash/hives, eczema, or rhinitis. 

Surgery – denies surgical history

O.

Physical exam:

General: Patient is a 46-year-old female that presents as alert and orientated x3, is dressed appropriately and able to participate in assessment/interview process. Anxiety is present and due to unknown outcome regarding her ankle. Denies fatigue/weakness, fever, or recent changes to weight.

Vital Signs: BP 141/92    HR 99   R20   O2 99%   Temp 98.8F

Height: 64inches   Weight: 128lbs.  BMI: 22.0 (normal weight)

HEENT:

22. Head:Normocephalic, no indications of masses/tenderness upon palpation.  Scalp is moist and without presence of alopecia (hair evenly distributed).  Cranial nerves intact V and V11 are intact and face symmetrical and without presentation/indication of paralysis or involuntary movement.
23. Eyes: Sclera white and conjunctivae pink bilaterally.Pupils equal, round, reactive to light, and accommodation (PERRLA); eyes symmetric and placed evenly/appropriately in orbits.  No indication/presentations of redness, discharge/drainage. Cranial nerves 2-4 intact.
24. Ears: Ear lobes parallel