Assessing Musculoskeletal Pain Case study

Assessing
Musculoskeletal 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 provides 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.

You will consider
case studies that describe abnormal findings in patients seen in a clinical
setting.

This
week you will be working on a case study. Write an
episodic/focused note about the patient in the case study to which you were
assigned using the episodic/focused note template provided in the 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.

Case Study’s
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 Ottawa
ankle rules to determine if you need additional testing?
Rubric:
Answers all parts of the Discussion question(s)
with reflective critical analysis and synthesis of knowledge gained from the
course readings for the module and current credible sources. Supported by at
least three current, credible sources. Written clearly and concisely with no
grammatical or spelling errors and fully adheres to current APA manual writing
rules and style.

Use at least 3 peer reviewed references dated
five years or less (2016-2021)
Use in text heading to resto to questions.

Episodic/Focused SOAP Note Template

Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying
why the patient is here – in the patient’s own words – for instance
“headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your
note. Thorough documentation in this section is essential for patient care,
coding, and billing analysis. Paint a picture of what is wrong with the
patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI
with age, race, and gender (e.g., 34-year-old AA male). You must include the
seven attributes of each principal symptom in paragraph form not a list. If the
CC was “headache”, the LOCATES for the HPI might look like the following
example:
Location:
head
Onset:
3 days ago
Character:
pounding, pressure around the eyes and temples
Associated
signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing:
after being on the computer all day at work
Exacerbating/
relieving factors: light bothers eyes, Aleve makes it tolerable but not
completely better
Severity:
7/10 pain scale
Current Medications: include dosage, frequency, length of time used
and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental
allergies separately (a description of what the allergy is ie angioedema,
anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last
tetanus for all adults), past major illnesses and surgeries. Depending on
the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco
& alcohol use (previous and current use), any other pertinent data. Always
add some health promo question here – such as whether they use seat belts all
the time or whether they have working smoke detectors in the house, living
environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic
predisposition, contagious or chronic illnesses. Reason for death of any
deceased first degree relatives should be included. Include parents,
grandparents, siblings, and children. Include grandchildren if pertinent.
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 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:
Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies
headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the
extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies
muscle, back pain, joint pain or stiffness.
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.
O.
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 that are
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.
Diagnostic results:
Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses (support with evidenced and guidelines)
A.
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.
P.

References
You are required to
include at least three evidence based peer-reviewed journal articles or evidenced
based guidelines which relates to this case to support your diagnostics and
differentials diagnoses. Be sure to use correct APA 7th edition
formatting.

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