Assessing Musculoskeletal Pain
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Assessing Musculoskeletal Pain
Patient Information:
Initials – SJ Age – 42 Sex – M Race – White
S.
CC: Lower back pain that sometimes radiates from the left leg.
HPI: 42-year-old male visits to the clinic complaining of lower back pain. The patient explains the pain begun one month ago. He also explains that the pain sometimes radiates from the left leg. He does not state why the pain started. He is currently taking ibuprofen but with little progress. The pain is affecting his movement. The severity of the pain is 7 out of 10.
Current Medications:
Ibuprofen 800mg OTC Q4H PRN for a week to relieve the pain.
Metformin 500mg daily to lower blood sugar levels.
Allergies:
Allergic to penicillin, not allergic to hay, cold or dust, and no other allergies to food, water, or drugs.
PMHx:
Started experiencing lower back pain one month ago. She continues to take her medication for type 2 diabetes. Diabetes is well-controlled. All vaccines are up to date.
Soc Hx:
The patient works at a local gym. He also goes hiking over the holiday. The patient is divorced, but he lives with his three sons and one daughter who are 10, 13, 15, and 12 respectively. He is not sexually active since they separated from his wife. He denies alcohol consumption or drug abuse. He attends a church service on Sunday at a Catholic church.
Fam Hx:
The patient’s father died 5 years go after they both succumbed to a heart attack and hypertension. His mother died 3 years ago after suffering from a stroke. He has three sisters who are all healthy. His children are all healthy and he has no grandchildren.
ROS:
GENERAL:
No unintentional weight loss or gain for the last 12 months. He denies any fever. The patient complains of lower back pain that radiates to his left leg.
HEENT: Eyes – He denies of blurred vision or yellow sclera or sensitivity to bright light. He uses sunglasses since he is shortsighted. Ears – He denies hearing problems, pain, or discharge from his ears. Nose – He denies pain, nasal congestion, or running nose. Throat – He denies any swallowing problem or pain, no tonsil problems or
SKIN: He denies skin rashes, bruises, lesions, itchiness, or dry plaques.
CARDIOVASCULAR: The patient complains of no discomfort such as chest tightness, edema, palpitations, and angina.
RESPIRATORY: He denies breathing problems, coughing, sputum, or shortness of breath.
GASTROINTESTINAL: The patient denies loss of appetite, eating disorder, blood in the stool, or diarrhea.
GENITOURINARY: He denies any difficulty in passing urine or burning sensation.
NEUROLOGICAL: He denies headache, seizures, falls, poor bowel, or bladder control.
MUSCULOSKELETAL: The patient reports no broken bone or fracture or muscle pain. He only reports lower back pain that radiates that sometimes radiates to the left leg.
HEMATOLOGIC: The sick person denies bleeding gums, anemia, or bruising.
LYMPHATICS: The patient does not complain or any tonsils or enlarged lymph nodes.
PSYCHIATRIC: The patient denies any history of anxiety, insomnia, depression, or suicidal thoughts.
ENDOCRINOLOGIC: The patient denies any excessive sweating at night, thirst, or urgent need to urinate.
ALLERGIES:
Allergic to penicillin, not allergic to hay, cold or dust, and no other allergies to food, water, or drugs.
O.
Physical exam:
Vital signs: Pulse 82, RR 20, Wt 140lbs, T 98.5F, BP 118/90, H 5’9.
Neurological: A, A & O.
Skin: Dry and warm. No lesions, wounds, or rashes.
Lungs: No adventitious sounds or abnormalities. Both lungs are clear.
Cardiovascular: No abnormal sounds and has an optimal heart rate.
Abdomen: Hyperactive bowel sounds absent and no masses identified.
Peripheral vascular: Optimal pulse and no edema.
HEENT: Has no abnormalities.
Musculoskeletal: Lower back pain that radiates to the left leg. No history of arthritis.
Diagnostic Tests:
The X-ray report will show the position and condition of the spine. The purpose is to determine if the spine is in the right position. Magnetic Resonance Imaging MRI is also necessary to carry out further assessment of the herniated lumbar disc (Traeger et al., 2019). MRI is also essential to show overgrown bones or compressed nerves by any herniated disc (Madsbu et al., 2018). It is also essential to carry out a CT scan since it will help rule out some of the other conditions that lead to lower back pain. Some of the conditions that lead to lower back pain include spinal column damage (Madsbu et al., 2018). Carrying out the three tests is essential to assess the source of the lower back pain by determining the condition of the spine and nerves.
A.
Differential Diagnoses:
The differential diagnosis of the lower back will include the following conditions:
a) Herniated lumbar disc – The herniated lumbar disc is a condition that can lead to lower back pain (Kanat et al., 2017). A herniated disc leads to pain due to the pressure on the surrounding nerves. The pain can radiate to the left or right leg. Some of the major symptoms include lower back pain and body weakness. It also causes difficulty in movement. One of the major causes of a herniated lumbar disc is strenuous activities (Huliyappa et al., 2017). Providers can diagnose the condition using MRI, CT scan, and X-ray for a detailed analysis of the condition and ruling out possible causes. Herniated lumbar disc is the most possible condition the patient is suffering from.
b) Spinal stenosis – Spinal stenosis occurs due to compression of the nerves as a result of the narrowing of the spinal cord. Some of the symptoms include pain, numbness, and poor bladder control (Madsbu et al., 2018). Providers diagnose the condition using an MRI scan, CT scan, and X-ray.
c) Ankylosing spondylitis – The condition is an inflammatory disease that leads to the growth of small bones on the spine. Therefore, the spine becomes less flexible. Patients hunch forward due to disrupted posture (Namas et al., 2019). It leads to lower back pain. Providers diagnose the condition using an MRI scan, CT scan, and X-ray. The reports should show inflammation due to the growth of the bones.
d) Sciatica – Sciatica is a health condition that affects the sciatica nerves. It is one of the longest nerves in the body from the spine to the legs. If the nerve is compressed or interfered with, it causes irritation and pain. It is one of the major causes of lower back pain (Traeger et al., 2019). It occurs due to spondylolisthesis, muscle spasms, or degenerative spine (Traeger et al., 2019). The diagnosis requires an MRI, CT scan, and X-ray. Medical history of the patient and a physical examination are necessary.
e) Muscle strain – A muscle strain occurs when the muscles are torn or stretched. It occurs if a person is engaging in strenuous activities (Traeger et al., 2019). Some of the major symptoms include pain and swelling. It requires an X-ray for diagnosis.
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Student Signature Date
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Preceptor Signature Date
References
Huliyappa, H. A., Singh, R. K., Singh, S. K., Jaiswal, M., Jaiswal, S., Srivastava, C., … & Chhabra, S. (2017). Transdural herniated lumbar disc disease with muscle patch for the closure of durotomy–A Brief review of the literature. Neurologia i Neurochirurgia Polska, 51(2), 149-155.
Kanat, A., Yazar, U., Ozdemir, B., Kazdal, H., & Balik, M. S. (2017). Neglected knowledge: Asymmetric features of lumbar disc disease. Asian Journal of Neurosurgery, 12(2), 199.
Madsbu, M. A., Salvesen, O, Werner, D. A., Franssen, E., Weber, C., Nygaard, P., … & Gulati, S. (2018). Surgery for herniated lumbar disc in daily tobacco smokers: a multicenter observational study. World Neurosurgery, 109, 581-587.
Namas, R., Hegazin, S. B., Memişoğlu, E., & Joshi, A. (2019). Lower back pain as a manifestation of acute gouty sacroiliitis: Utilization of dual-energy computed tomography (DECT) in establishing a diagnosis. European Journal of Rheumatology, 6(4), 216.
Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. Cmaj, 189(45), 1386-1395.
