Initials: C.A, Age: 46 years, Sex: Female, Race: African American
S.
CC (chief complaint): Bilateral ankle pain
HPI: C. A is a 46 is African American aged 46 years old. She presents with complaints of pain in her bilateral ankle, especially on the right side. She claims to have heard a “pop” while playing soccer over the weekend. She can tolerate weight, but it is painful. Her major worry is her right ankle.
Location: Bilateral ankle
Onset: Abrupt
Character: Sharp but not radiating pain
Associated signs and symptoms: Ankle enlargement and inadequate right ankle movement.
Timing: The pain has lasted for two days. It is irregular with each episode taking about 15-20 minutes.
Exacerbating/ relieving factors: Pain is intensified by walking, tolerating weight, or sitting. Pain is momentarily eased by cold compresses.
Severity: Pain is worse on the right ankle at about 5/10 compared to the left ankle which is about 2/10.
Current Medications: None
Allergies: No identified drug and food allergies
Past Medical History: No history of chronic medical conditions, blood transfusion, or previous surgeries. Flu vaccine: December 2020
Social History: She is a professional teacher and the team’s soccer captain. She likes playing soccer on weekends. She does not take alcohol, smoke tobacco, or use illicit drugs.
Family History: Her parents are all alive. Her mother is diabetic but effectively managed by metformin. She is not living with her husband because they separated two years ago. She has a 20-year-old college-going daughter.
ROS:
GENERAL: No fever, chills, night sweats, or changes in weight
HEENT: Eyes: Refutes loss of vision, blurred vision, or yellow sclera. Ears, Nose, and Throat: Refutes ear discharges, hearing loss, dysphagia, nasal congestion, or sore throat.
SKIN: Reports no rash, itching, or skin discoloration.
CARDIOVASCULAR: No paroxysmal nocturnal dyspnea, palpitation, chest pain, or orthopnea.
RESPIRATORY: No cough, shortness of breath, sputum, or difficulty in breathing. GASTROINTESTINAL: No alteration in changes in abdominal distention, or bowel routines.
GENITOURINARY: Refutes hematuria, frequency, or dysuria. The last menstrual period was on 07/09 /2022.
NEUROLOGICAL: Denies convulsion, headache, syncope, or alterations in the functions of bowel and bladder.
HEMATOLOGIC: No anemia, bruising, or bleeding.
LYMPHATICS: No record of splenectomy. No lymphadenopathy.
PSYCHIATRIC: Refutes anxiety, depression, hallucinations, or delusions.
ENDOCRINOLOGIC: No cold, polydipsia, polyuria, and heat intolerance.
ALLERGIES: No history of asthma, eczema, or hives.
O.
Physical exam
Vital Signs: P 78 RR 19 Temp 98.4 F, BP 123/74 mmHg, Weight 128 lbs., Height 5′ 5″
General: A middle-aged female adult of African American origin. She has a minor discomfort. She is oriented and alert.
Respiratory: Vesicular breath sounds in entire lung zones, a symmetric chest that budges with respiration. No crackles or wheezing.
Cardiovascular: No murmurs. PMI in the fifth intercostal space, normoactive precordium, midclavicular line. S1 and S2 detected. Ecchymosis measuring 2 cm by 2 cm was noted around the lateral malleolus. Tenderness of the lateral malleolus was observed, particularly above the anterior talofibular ligament. Restricted range of motion of the right ankle, especially on plantar flexion, inversion, and dorsiflexion. Bilateral skin intact. No noted erythema or edema on the left ankle. The usual range of motion was noted on the left ankle. Noted bilateral constructive dorsalis pedis. Bilateral intact sensation, No noted deformity, crepitus, or bony tenderness.
Neurological: GCS 15/15, oriented to person, place, and time. Cranial nerves are intact, sensation in every dermatome is intact, and typical bulk, typical tone, and reflexes in all joints. Regular functions of bladder and bowel.
Diagnostic results:
The prone anterior drawer test: This test evaluates the reliability of the ankle’s lateral ligamentous complex. The test is crucial for the patient’s case.
Talar tilt test: This test focuses on the calcaneofibular ligament. The patient suffered pain around the ligament area.
Eversion test: This test is conducted to assess the reliability of the deltoid ligament. It is negative in the patient’s case.
Imaging: Based on the Ottawa Ankle rules, conducting a series of X-rays is crucial is necessary where the pain is noted in the malleolar area alongside any of the following signs; tenderness above the posterior periphery of the distal 6 cm or medial malleolus’ tip, tenderness above the posterior periphery of the distal 6 cm or lateral malleolus’ tip, and incapacity to tolerate weight shortly following an injury (Murphy et al., 2020). The patient, C.A, met the Ottawa rules. As a result, a right lateral X-ray was conducted, which indicated swelling in the soft tissue. There is a need for an MRI of the ankle or more perspectives to effectively describe the ligaments involved.
A.
Differential Diagnoses
Lateral Ankle Sprain: This pain is a frequent injury associated with sports. It occurs majorly with the ankle inversion and entails the lateral ligamentous complex, which comprises the calcaneofibular and posterior talofibular ligament, and anterior talofibular ligament that are damaged in reducing order (Martin et al., 2021). Patients with this condition often have a hematoma, tenderness above the sprained ligament, inadequate range of motion, and soft tissue swelling. These characteristics are common with the patient in this case. The “pop” sound she reported is an indication of a clear ligament tear. As such, lateral ankle sprain is the primary diagnosis in this patient.
Ankle Fracture: This condition characterizes one or more ankle joint bones including the tibia, talus, and fibular. It presents as a cute immediate pain, tenderness, incapacity to tolerate weight, limited movement, pain, skin abnormalities, and swelling (McKeown et al., 2020). It is not the major diagnosis since ankle fractures are normally high-energy injuries but the patient can tolerate the weight.
Syndesmotic Ankle Injury: This condition is also called a high ankle sprain. It characterizes an injury to a minimum of one of the ligaments that encompass the distal tibiofibular syndesmosis (Raheman et al., 2022). It is also attributed to injuries associated with sports with an abrupt twisting force. It leads to more proximal pain above the ankle.
Anterior Impingement: This condition connotes strapped structures down the tibiotalar joint’s anterior margin in terminal dorsiflexion (Chen et al., 2019). It often characterizes ankle pain and restricted movement. It is also linked to considerable abnormalities in the osseous and soft tissues.
Achilles Tendinitis: This condition characterizes Achilles tendon inflammation. It manifests with swelling, pain, and erythema at the point of tendon placement into the calcaneus. It also manifested in incapability to move and tightness (Lee & Lee, 2018). In the case at hand, the patient reported pain and tenderness in the ankle’s lateral area. However, in Achilles tendinitis, the pain should manifest in the posterior area of the ankle.
This section is needless in this course. However, it will be necessary for future courses.
References
Chen, L., Wang, X., Huang, J., Zhang, C., Wang, C., Geng, X., & Ma, X. (2019). Outcome comparison between functional ankle instability cases with and without anterior ankle impingement: a retrospective cohort study. The Journal of Foot and Ankle Surgery, 58(1), 52-56. https://doi.org/10.1053/j.jfas.2018.07.015
Lee, Y. K., & Lee, M. (2018). Treatment of infected Achilles tendinitis and overlying soft tissue defect using an anterolateral thigh free flap in an elderly patient: A case report. Medicine, 97(35). Doi: 10.1097/MD.0000000000011995
Martin, R. L., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Carroll, L. A., … & Carreira, D. (2021). Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(4), CPG1-CPG80. https://www.jospt.org/doi/10.2519/jospt.2021.0302
McKeown, R., Kearney, R. S., Liew, Z. H., & Ellard, D. R. (2020). Patient experiences of an ankle fracture and the most important factors in their recovery: a qualitative interview study. BMJ open, 10(2), e033539. http://dx.doi.org/10.1136/bmjopen-2019-033539
Murphy, J., Weiner, D. A., Kotler, J., McCormick, B., Johnson, D., Wisbeck, J., & Milzman, D. (2020). Utility of Ottawa ankle rules in an aging population: evidence for addition of an age criterion. The Journal of Foot and Ankle Surgery, 59(2), 286-290. https://doi.org/10.1053/j.jfas.2019.04.017
Raheman, F. J., Rojoa, D. M., Hallet, C., Yaghmour, K. M., Jeyaparam, S., Ahluwalia, R. S., & Mangwani, J. (2022). Can weightbearing cone-beam CT reliably differentiate between stable and unstable syndesmotic ankle injuries? A systematic review and meta-analysis. Clinical Orthopaedics and Related Research®, 10-1097. Doi: 10.1097/CORR.0000000000002171
Sample Answer for NURS 6512 Discussion: Assessing Musculoskeletal Pain Included After Question
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.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
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.
Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
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
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
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?
Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
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?
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 of Week 8
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 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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 8
Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.
A Sample Answer For the Assignment: NURS 6512 Discussion: Assessing Musculoskeletal Pain
Title: NURS 6512 Discussion: Assessing Musculoskeletal Pain
S.
CC: “low back pain”HPI: The patient is a 42 year old WM male who developed low back pain that radiates to his left leg two months ago. The pain is described as sharp, aching and sometimes burning. He rates pain at a 7/10 in terms of intensity and its increases with activities such as bending, lifting, and twisting, activities required in his occupation daily.
Medications: Tylenol 1000mg as needed for pain, Advil 800mg as needed for pain, 40mg
PMH: Positive history of GERD
FH: Mother has a hx of stomach cancer, but is still living; Father has HTN. No history of premature cardiovascular disease in first degree relatives.
SH : Smokes 1 pack of cigarettes daily x 10 years, drinks 1-3 beers on the weekends while watching the game; divorced for the last 5 years –
Allergies: NKDA including medications, food, and environmental
Immunizations: UTD on immunizations
ROS
General–Negative for fevers, chills, fatigue, fluctuation in weight
Cardiovascular–Negative for orthopnea, edema, palpitations
Gastrointestinal—Negative for nausea, vomiting, diarrhea, abdominal pain
Pulmonary—Negative for dyspnea on exertion, negative for cough or hemoptysis
Musculoskeletal-Negative for joint pain, swelling, or notable bone deformity. Denies weakness
O.
VS: BP 142/96; P 89; R 22; T 97.2; 02 95% Wt 205lbs; Ht 72”
General–Pt appears uncomfortable, no s/s of diaphoresis, fever, or pallor
Cardiovascular—Negative for JVD, carotid bruit. S1 et S2 noted per auscultation, RRR. Negative for murmurs
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; negative for
bruits. No masses or splenomegaly are noted. Negative for pain or tenderness
Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Musculoskeletal-Negative for joint pain, swelling, or heat. ROM intact. Negative for muscle weakness. Positive for pain when moving left lower extremity and bending over. C/o low back pain that sometimes radiates to his left leg.
Diagnostic results: Weight bearing radiographs of the lumbar spine, complete blood count, erythrocyte sedimentation rate, c-reactive protein
A.
Differential Diagnosis:
Sciatica-
Sciatica pain often starts in the lower back and radiates down the posterior and lateral aspects of the leg (Dains et al., 2019). In addition, sciatica is due to nerve root compression (Ball et al., 2023). These repetitive activities have been identified as an occupational and lifestyle hazard for our patient.
Lumbar Disk Herniation-
Lumbar disk herniation can cause low back and leg pain (Benzakour et al., 2019). Pain associated with a lumbar disk herniation is often described as tingling, prickling, or burning (Hasvik et al., 2022)
Spinal Stenosis
Spinal Stenosis presents with pain in the lower back and thigh (Katz et al., 2022). Pain may continue to progress to the lower leg and foot. The patient may eventually experience difficulty with ambulation, but this doesn’t necessarily occur immediately.
Arachnoiditis
Arachnoiditis can present as burning low back pain that travels down the leg (Maillard et al., 2023)
Spondylolysis
Spondylolysis can cause lumbar back pain that is typically relieved with rest (Li et al., 2022). The disease may progress to nerve compression.
Primary Diagnosis/Presumptive Diagnosis: Sciatica
Involved Nerve Roots and Testing
Sensation is the first tool involved in testing nerves roots that protrude from the lumbar spine. This can be done using a sharp object lightly applied to random areas and ask the patient to differentiate between sharp and dull.
The Patellar Reflex evaluates nerves between L2 and L4. is tested by striking the tendon directly below the patella.
The Achilles Reflex is utilized to evaluate the nerves between L5 to S2. With the knee flexed and the hip externally rotated, hold the foot in dorsiflexion and strike the Achilles tendon.
The Plantar Reflex evaluates nerves between L4 and S2. The end of the reflex hammer is drawn lightly up the lateral side of the sole of the foot and across the ball of the foot.
Symptoms to Explore
Additional symptoms that should be explored include loss of control of bowels or bladder, and numbness on the medial aspects of the thighs. In addition, motor strength in the back and lower extremities should be evaluated.
Maneuvers to Perform
Two assessment maneuvers would be very important to do for this client. The first is the Patrick’s Test (Urits et al, 2019). This consists of having the patient lie supine while the leg is passively flexed, abducted, and externally rotated. If the client experiences pain in the groin, this is indicative of hip pathology. If pain is experienced in the low back, this indicates pathology with the sacroiliac joint.
Secondly, the Straight Leg Test should be performed to determine nerve root involvement (Urits et al., 2019). This test is performed while the patient lies supine. The patient’s leg is lifted at the heel with the keep straight. The hip is flexed to a 70-90 degree angle. If the radicular pain is reproduced, the test is positive.
Support for Diagnostic Tests
Since the patient is presenting with symptoms for longer than 4 weeks, we can start by getting weight bearing radiographs of the lumbar spine (Urits et al., 2019). If pain persists despite minimally invasive treatments, further imaging such as an MRI, may be necessary. Laboratory tests including a complete blood count, erythrocyte sedimentation rate, and c-reactive protein should be performed to ensure the patient does not have any kind of bacterial infection at the site (See et al., 2021)
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International Orthopaedics, 43(4), 841–851. https://doi.org/10.1007/s00264-018-4247-6
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.
Hasvik, E., Haugen, A. J., & Grøvle, L. (2022). Symptom descriptors and patterns in lumbar radicular pain caused by disc herniation: a 1-year longitudinal cohort study. BMJ Open, 12(12), e065500. https://doi.org/10.1136/bmjopen-2022-065500
Katz, J. N., Zimmerman, Z. E., Mass, H., & Makhni, M. C. (2022). Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA, 327(17), 1688–1699. https://doi.org/10.1001/jama.2022.5921
Links to an external site.
Li, N., Amarasinghe, S., Boudreaux, K., Fakhre, W., Sherman, W., & Kaye, A. D. (n.d.). Spondylolysis. Orthopedic Reviews, 14(3), 37470. https://doi.org/10.52965/001c.37470
Maillard, J., Batista, S., Medeiros, F., Farid, G., Paulo Santa Maria, Perret, C., Koester, S. W., & Bertani, R. (2023). Spinal Adhesive Arachnoiditis: A Literature Review. https://doi.org/10.7759/cureus.33697
See, Q., Tan, B., & Kumar, D. (2021). Acute low back pain: diagnosis and management. Singapore Medical Journal, 62(6), 271–275. https://doi.org/10.11622/smedj.202108
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). https://doi.org/10.1007/s11916-019-0757-1
A Sample Answer 2 For the Assignment: NURS 6512 Discussion: Assessing Musculoskeletal Pain
Title: NURS 6512 Discussion: Assessing Musculoskeletal Pain
SUBJECTIVE DATA:
Chief Complaint (CC): “Pain in my lower back for the past one month”
History of Present Illness (HPI): S.K is a 42-year-old Caucasian male patient who reported to the clinic with pain in his lower back that had lasted for about a month. he reports that the pain radiates to his left leg sometimes. The patient reports that the pain is worse when working, and is less disturbing when resting. He has been taking ibuprofen which he claims to provide minimal relief.
Location: lower back
Onset: about a month ago
Character: constant and sharp pain radiating to the left leg
Associated signs and symptoms: None
Timing: When handling strenuous work
Exacerbating/ relieving factors: Any movement worsens the pain. Resting and Ibuprofen provides minimal relief.
Severity: 7/10 on a pain scale
Medications:
Ibuprofen 800mg PO PRN for the back pain
Allergies:
No known environmental, food, or drug allergies.
Past Medical History (PMH):
Denies any history of a serious medical diagnosis
Past Surgical History (PSH):
Denies ever undergoing any surgical procedure in the past.
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
Married with 3 children
Works in a book store downtown.
Has never smoked tobacco or marijuana.
Confirms taking 2 to 3 beers occasionally when with friends.
Immunization History:
Flu shot 17/2/2022
Covid Vaccine #1 2/1/2021 #2 3/1/2021 Moderna
All other immunization up to date
Significant Family History:
Mother- with HTN and DM
Father- with gout and kidney disease
Maternal grandmother- with kidney disease
Maternal grandfather- died from a stroke
Paternal grandmother- with COPD
Paternal grandfather with CAD, HTN, and COPD.
He has 2 daughters and one son who are all healthy with no significant health complications.
Lifestyle:
The patient works in a bookstore downtown. He is happily married to a junior school teacher with 3 children. They live on the
outskirts of the city in a 3 bedroom apartment in a safe neighborhood. The means of transport is good, with easily accessible fresh water and healthcare services. He tried as much as possible to eat a healthy diet together with his family. He walks the dog every evening for about a kilometer as a form of exercise. Uses seat belts when in the car, with safety equipment such as a first-aid kit available in their home. He is a strong church member and socializes with his friends mostly over the weekend.
Review of Systems:
General: No recent changes in body weight. Complains of pain in his lower back. Denies constipation, fatigue, chills, fever, or generalized body weakness.
HEENT: Head: No signs of trauma or headache reported. Eyes: Denies blurred vision, use of corrective lenses, excessive tearing, or redness. Ears: No tinnitus, itchiness, or hearing loss. Nose: no congestion, running nose, sinus problems, or nose bleeding. Throat & Mouth: No sore throat, coughing, swallowing difficulties, or dental problems. Neck: No tenderness, signs of injury, enlarged tonsils, or a history of disc disease or compression.
Respiratory: No wheezing, coughing, shortness of breath, or breathing difficulties.
CV: Denies chest pain, edema, PND, orthopnea, syncope, or palpitations. Dyspnea on exertion
GI: No abdominal tenderness, constipation, diarrhea, distention, changes in bowel movement, or jaundice.
GU: Denies incontinence, urinary frequency, hematuria, dysuria, or burning sensation when urinating.
MS: Reports lower back pain which sometimes radiates to the left leg. He rates the pain at 7/10 on a pain scale. The severity of the pain however worsens when walking or turning when sleeping. The patient confirms that the pain has lasted for about a month, making it harder to exhibit a full range of movement on the left leg. No numbness, swelling, or redness was reported.
Psych: Denies paranoia, hallucinations, delirium, suicidal ideation, mental disturbance, memory loss, anxiety or depression, or a history of psychosis.
Neuro: Reports back pain that radiates to the left leg. Denies vertigo, tremors, syncope, seizures, paresthesia, or transient paralysis.
Integument/Heme/Lymph: No bruising, ecchymosed, ulcers, lesions, or rashes. No signs of enlarged lymph nodes.
Endocrine: Denies heat intolerance, cold intolerance, polyuria, polyphagia, or polydipsia.
Allergic/Immunologic: Denies hay fever, urticaria, persistent infections, or HIV exposure.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 140/96, left arm, sitting, regular cuff; P 88 and regular; T 98.9 Orally; RR 18; non-labored; Wt: 215 lbs; Ht: 5’8; BMI 32.69
General: The patient appears healthy, and well oriented in person, place, and time. Seems to be uncomfortable and in moderate pain.
HEENT: External ears normal, with no deformities or lesions. External nose normal with no deformities or lesions. Bilaterally clear canals. Intact tympanic membrane with good movement and no fluid. Grossly intact bilateral hearing. Normal nasal mucosa, septum and turbinates. Complete and good hygienic dentation.
Neck: Supple with no masses. Trachea midline, No thyroid nodules, tenderness, or masses.
Chest/Lungs: Bilaterally clear to auscultation. Tactile fremitus normal. No signs of egophony. Normal respiratory effort displayed with no use of accessory muscles.
Heart/Peripheral Vascular: S1, and S2, note. Normal cardiac rhythm with no murmur, gallop, or rubs.
ABD: Suprapubic surgical scar, obese, non-tender, soft, and non-distended abdomen with no masses.
Genital/Rectal: The patient did not consent to this examination.
Musculoskeletal: Low back pain noted, radiating to the left lower leg. No evidence of trauma affecting the area was noted. Tenderness increases with extension, flexion, and twisting. Limited ROM in the left leg.
Neuro: Cranial nerves: II – XII grossly intact; 2+, symmetric, reflexes.
Diagnostics/Lab Tests and Results:
CBC – To evaluate for spinal infections
CSF analysis- For suspected spinal infection or inflammatory etiologies
X-ray of the spine- for flexion-extension views to identify spondylolisthesis and spinal instability.
MRI of the spine- to assess for suspected myelopathy or radiculopathy.
Electromyography (EMG)- to confirm compressions caused by spinal stenosis or herniated disks (Urits et al., 2019).
Assessment:
Differential Diagnosis (DDx):
Sciatica: This condition is characterized by pain that normally radiates along the sciatic nerve path, which branches from the patient’s lower back through to the buttocks and hip, and down to each leg (Kim et al., 2018). However, sciatica normally affects one side of the body. The patient in the provided case study presents with lower back pain that radiates to the left leg, which is a great indication of sciatica as the primary diagnosis.
Lumbar disc herniation: LDH is characterized by lower back pain and is common among adults between the age of 35 and 50 years. It normally results from changes in the structure of the lower lumbar spinal disk between the 4th and 5th vertebrae and between the 5th lumbar vertebra and the 1st sacral vertebra (Benzakour et al, 2019). Most patients normally present with symptoms such as lower back pain, radicular pain, limited trunk flexion, and weakness at the lumbosacral nerve roots distribution. The patient in the provided case study displayed lower back pain, however, an MRI of the spinal column is needed to confirm this diagnosis.
Lumbar spinal stenosis: LSS is associated with narrowing of the spinal canal located in the lower back resulting in pain. Stenosis causes pressure on the patient’s spinal cord or nerves connecting the spinal column and the muscles (Deer et al., 2019). As such patients will present with lower back pain just like the one in the provided case study. However physical examination is required to assess for the presence of loss of sensation, abnormal reflexes, and weakness to confirm this diagnosis.
Lumbar muscle strain: LMS is described as an injury to the lower back characterized by mild to moderate lower back pain. The injury can lead to damage to the muscle or tendons causing spasms and soreness (Urits et al., 2019). An x-ray is however needed to confirm the impact of the injury on the tendon or muscle to confirm the diagnosis
Ankylosing spondylitis: This is an inflammatory disorder, that can lead to some of the spinal bones fusing over time. It is characterized by pain in the joints and the back (Ogdie et al., 2019). Symptoms normally appear early in life, including reduced flexion of the spine. The patient only presented with back pain which radiates to the left leg with no joint pain or reduced flexion of the spine.
Primary Diagnoses:
1.) Sciatica
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.]
References
Benzakour, T., Igoumenou, V., Mavrogenis, A. F., & Benzakour, A. (2019). Current concepts for lumbar disc herniation. International orthopedics, 43(4), 841-851. https://doi.org/10.1007/s00264-018-4247-6
Deer, T. R., Grider, J. S., Pope, J. E., Falowski, S., Lamer, T. J., Calodney, A., … & Mekhail, N. (2019). The MIST guidelines: the Lumbar Spinal Stenosis Consensus Group guidelines for minimally invasive spine treatment. Pain Practice, 19(3), 250-2
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