Assessment of the Musculoskeletal System
Student’s Name
Post- Master’s Certificate Adult-Gerontology Acute Care NP, Walden University
Advanced Health Assessment and Diagnostic Reasoning - NURS 6512
Instructor
July 2022
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NURS 6512 NRNP 6512 SOAP Note Musculoskeletal
Typology: Assignments
2022/2023
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Assessment of the Musculoskeletal System Student’s Name Post- Master’s Certificate Adult-Gerontology Acute Care NP, Walden University Advanced Health Assessment and Diagnostic Reasoning - NURS 6512 Instructor July 2022
Patient Initial: Age: 42 Gender: Male SUBJECTIVE DATA: CHIEF COMPLAINT (CC): “Lower back pain” HISTORY OF PRESENT ILLNESS (HPI): Patient AB, a 42-year-old African American male visited the clinic today complaining lower back pain that began about a month ago. The patient stated the pain sometimes radiates to his left leg. He rates the current pain as 6 out of 10 but complaints that it can go to as high as 9/10. He takes Ibuprofen 800mg every six hours as needed without relief. LOCATION: Lower back ONSET: One month ago CHARACTER: Sharp, constant, radiating to left leg TIMING: Starts when at work EXACERBATING FACTORS: Any movement Ibuprofen helps relieve pain temporarily. SEVERITY: Pain scale ranges from 6 to 9 out of 10. MEDICATIONS: LBP - Ibuprofen 800 mg every six hours HTN – Amlodipine 10mg daily ALLERGIES: No history of asthma, hives, eczema, or rhinitis. NKDA. PAST MEDICAL HISTORY (PMH): Diagnosed with Hypertension a year ago.
MUSCULOSKELETAL: Lower back pain radiating to left leg. Denies joint pain and stiffness. Denies bleeding. NEUROLOGICAL: Denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. HEMATOLOGIC: Denies bleeding. ENDOCRINE: Denies intolerance in heat and cold, excessive thirst, thyroid problem, and urination. PSYCHIATRIC: Denies mental problems and depression. OBJECTIVE DATA: PHYSICAL EXAM: VITAL SIGNS: BLOOD PRESSURE: 120/ HEART RATE: 68 TEMPERATURE: 98. PULSE RATE: 95 RESPIRATORY RATE: 30 WEIGHT: 160 lbs HEIGHT: 5’9” BODY MASS INDEX: 26
NEUROLOGICAL: Patient has good judgment. He is aware and oriented to place, person, time, and situation. No facial drooping and no changes in vision. Speech is clear. Follows movement. Patient understands clear, complex, and comprehensive without observed cues or repetitions. SKIN: Not pale, cyanosis or ashen. Dry and warm to touch. No tear and non-tainting. HEENT: Head: Normocephalic, fontanels are closed, suture lines intact, hair evenly distributed. Eyes: PERRLA, sclera white, conjunctiva pink, extra ocular movements intact; no hemorrhage or exudate noted. Ears: External appearance normal-no lesions, redness, or swelling; on otoscopic exam right tympanic membrane and inner ear is red; yellowish fluid is also noted behind the tympanic membrane. Hearing is intact. NOSE: Nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge. NECK: Neck symmetrical, supple, full ROM, non-tender without masses. THROAT/MOUTH: Oral mucosa pink and moist. Pharynx without erythema, exudates, or lesions. LUNGS: Tachypnea, the chest expands symmetrically, bilateral breath sounds are clear. HEART/PERIPHERAL VASCULAR: The heart rate is regular with a normal rhythm, S1and S2 sound heard. All peripheral pulses are strong and palpable +3, Negative edema to all
compresses the nerve root below the herniation causing pain and dysfunctional symptoms. As a result, L5 and S1 are primarily involved in nerve root compression and in majority radiculopathy cases involve a single root L5 or S (Fang et al., 2016; Schoenfeld & Weiner, 2010; Bartynski et al., 2010). Herniated disc pain differs from mechanical back pain, often radiates into lower extremity and frequently burning or stinging. This diagnosis is a prevalent clinical illness with a high occurrence rate. Most patients first complained of low back discomfort. Leg discomfort and radiating pain are the most common symptoms at this stage. In severe instances, patient will become debilitated resulting to a poor quality of life (Zheng et al., 2021). Neurologic discomfort in the leg and low back between 30-70 degrees of hip flexion indicates lumbar disc herniation at the L4- S1 nerve roots. Cheung and Luk (2019) reported the accuracy of MRI as significantly higher with 88% than CT scan with 50% in the diagnosis of intervertebral disc herniation. The total detection rate of LDH by MRI is 96.67%, which is significantly higher than 71.67% of CT. MRI has been the gold standard in evaluating the relationship between soft tissues and neural structure of disc materials. LDH is initially diagnosed based on a medical history and a neurophysiological examination. Magnetic resonance imaging (MRI) is a common noninvasive approach for confirming the diagnosis of LDH and the compressed nerve root in patients with a history and neurophysiological evaluation compatible with radiculopathy. (Li et al., 2015). 2.) Lumbar Spinal Stenosis
Lumbar spinal stenosis is best characterized as a combination of clinical symptoms that include low back pain, bilateral lower extremities discomfort, paresthesias, and other neurologic impairments that occur together with physical constriction of the neural route through the spine. As a result of the altered biomechanical properties of the spinal segment, a cycle of degenerative changes is perpetuated causing radicular pain via a combination of inflammatory mediators, direct mechanical compression of nerve roots, and restricted microvascular circulation and axoplasmic flow. A precise anatomical representation and categorization of the stenosis can be obtained using MR tomographic imaging. Although advanced imaging technologies provide a very accurate picture of lumbar spinal stenosis, clinical symptoms play an important role in therapeutic decision-making. Differentiated surgical decompression of the spinal canal can be planned using anatomical interpretations (Daffner & Wang, 2009). 3.) Sciatica A debilitating condition involving the L4 and S2 nerve roots results specific pain to sciatic nerve pathology. Sciatic nerve measures up to 2 cm in diameter, is the largest nerve in the body providing numerous functions. It is crucial to understand the most sciatica cases causing an inflammatory condition can result to a sciatic nerve irritation. Direct compression of the nerve, on the other hand, results in more severe motor dysfunction, which is frequently not detected and, if present, would require for a more thorough workup. With a variable sensitivity and specificity, a passive straight-leg-test examination is used for an out-patient clinical setting. From a posterior aspect, this is performed by lifting the leg,
Acute pain usually lasts for less than 7 days but often extends up to 30 days and may recur periodically. Back pain, a musculoskeletal condition is the most prevalent qualifying diagnosis (AHRQ, 2020) which accounts for 34 percent of program participants according to Social Security Disability Insurance in 2011. Back discomfort is a prime determinant of disability and can persist from childhood into adulthood. Back pain is a major cause of morbidity and death. The initial diagnostic evaluation for low back pain includes a history and physical examination. Characterizing nociceptive pain (mechanical) from neuropathic pain (radiculopathy) is an important initial step in the diagnosis of back pain. What nerve roots might be involved? Back pain nerve roots reveal a diverse, heterogeneous condition in which both nociceptive and neuropathic pain processes may be involved. Activation of the set nociceptors innervating ligaments, joints, muscles, fascia combined with tendons causes the pain due to possible tissue trauma or biomechanical stress (Baron et al., 2016). A disc protrusion at L4/L compresses the L5 root, whereas a protrusion at L5/S1 compresses the S1 root. The L4/5 or L5/S1 disc spaces account for 95% of disc herniations. Higher-level herniations are infrequent. Moreover, AHRQ Quick Reference Guide (1994) on Acute Low Back Problems in Adults states a 90-percent clinically relevant lower extremity radiculopathy cases is caused by disc herniation associated with L5 or S1 nerve root at the L4-5 or L5-S1 disc level. How would you test for each of them? What physical examination will you perform? What special maneuvers will you perform? A complete blood count, erythrocyte sedimentation rate measurement, urinalysis and other tests as required by the clinical assessment may be part of the comprehensive evaluation.
Special tests, such as the straight leg raise can aid in determining the source of the pain. The history concentrates on the onset of pain. These tests are especially important when malignancy is suspected as a cause of a complaint back pain. A bone scan can reveal physiological responses to a possible spinal tumor, infection, or concealed fracture. If physiologic data indicates tissue injury or nerve dysfunction, speak with a specialist about the best imaging test to rule out a possible anatomic cause namely CT for bone, MRI for neural or other soft tissue (AHCPR, 1994). What other symptoms need to be explored? Symptoms such as weakness, sensory changes, difficulties ambulating, bowel or bladder changes, fever, chills, unexplained weight loss, and discomfort waking the patient up are also relevant inquiries to rule out serious disease (Allegri et al., 2016). Low back distress can also be a symptom of a serious medical problem, such as diabetes or a pinched nerve. Pain from a pinched nerve may be accompanied by symptoms such as fever, chills, night sweats, or loss of bladder control (Watson, 2011). Other differential diagnoses for ALBP: Additional diagnoses noted by Casiano et al. (2022) include inflammatory illnesses, cancer, pregnancy, trauma, osteoporosis, nerve root compression, radiculopathy, plexopathy, degenerative disc disease, sacroiliac joint dysfunction, facet joint damage, and infection. Depicting a state of red patches in the skin that causes pain within the joints (Mayo Clinic, 2019) can be diagnosed to psoriatic arthritis, this may be a possible condition for ALBP.
Baron, R., Binder, A., Attal, N., Casale, R., Dickenson, A. H., & Treede, R. D. (2016). Neuropathic low back pain in clinical practice. European journal of pain (London, England) , 20 (6), 861–873. https://doi.org/10.1002/ejp. Bartynski, W. S., Kang, M. D., & Rothfus, W. E. (2010). Adjacent double-nerve root contributions in unilateral lumbar radiculopathy. AJNR. American journal of neuroradiology , 31 (2), 327–333. https://doi.org/10.3174/ajnr.A Casiano, V. E., Sarwan, G., Dydyk, A. M., & Varacallo, M. (2022). Back Pain. In StatPearls. StatPearls Publishing. Cheung, J., & Luk, K. (2019). The relevance of high-intensity zones in degenerative disc disease. International orthopaedics , 43 (4), 861–867. https://doi.org/10.1007/s00264-018-4260- Daffner, S. D., & Wang, J. C. (2009). The pathophysiology and nonsurgical treatment of lumbar spinal stenosis. Instructional course lectures , 58 , 657–668. Davis, D., Maini, K., & Vasudevan, A. (2022). Sciatica. In StatPearls. StatPearls Publishing. Fang, G., Zhou, J., Liu, Y., Sang, H., Xu, X., & Ding, Z. (2016). Which level is responsible for gluteal pain in lumbar disc hernia?. BMC musculoskeletal disorders , 17 (1), 356. https://doi.org/10.1186/s12891-016-1204- Li, Y., Fredrickson, V., & Resnick, D. K. (2015). How should we grade lumbar disc herniation and nerve root compression? A systematic review. Clinical orthopaedics and related research , 473 (6), 1896–1902. https://doi.org/10.1007/s11999-014-3674-y
Schoenfeld, A. J., & Weiner, B. K. (2010). Treatment of lumbar disc herniation: Evidence-based practice. International journal of general medicine , 3 , 209–214. https://doi.org/10.2147/ijgm.s Tawfik, S., Phan, K., Mobbs, R. J., & Rao, P. J. (2020). The Incidence of Pars Interarticularis Defects in Athletes. Global Spine Journal, 10 (1), 89–101. https://doi.org/10.1177/ Zheng, K., Wen, Z., & Li, D. (2021). The Clinical Diagnostic Value of Lumbar Intervertebral Disc Herniation Based on MRI Images. Journal of healthcare engineering , 2021 ,
- https://doi.org/10.1155/2021/ Watson, S. (2011). Top causes of chronic low back pain. WebMD, (Archives). https://www.webmd.com/back-pain/features/causes