Advanced Health Assessment Musculoskeletal Pain

Advanced Health Assessment Musculoskeletal Pain

Advanced Health Assessment Musculoskeletal 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?

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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?

Patient Information:

R.E, 42-year-old African American male

Subjective

CC: “Lower back pain”

HPI: A 42-year-old black African American male who came to the clinic today for complaining of lower back pain which he reported started a month ago. The patient stated that the pain sometimes radiates to his left leg.

 

Location: Lower back

Onset: One month ago

Character: Sharp, constant, radiating to left leg

Associated signs and symptoms: None

Timing: Starts when at work

Exacerbating/ relieving factors: Any movement. Ibuprofen helps to relief the pain temporarily.

Severity: 7/10 pain scale

Medications:

Ibuprofen 200mg 3 tablets every 6 hours PRN for lower back pain. Advanced Health Assessment Musculoskeletal Pain

Amlodipine 10mg daily for hypertension x1 years.

Allergies: No known drug allergy, no food allergy, no seasonal allergy and No known allergy to latex/rubber.

PMHx:

Hypertension diagnosed one year ago.

Influenza vaccine November of 2020.

Tdap vaccine 2018.

Pneumonia: Not yet had any pneumococcal vaccine.

Up to date on all childhood immunizations.

Past surgical history: None.

Social History: Mr. R.E is happily married with three children. He has a bachelor’s degree in medical laboratory and works in the hospital setting. Mr. R.E denies ever smoking, but he drinks Corona beer occasionally and during festive period with friends and family. He denies using any illicit drugs and the thought of suicidal ideation. He goes to the gym at least 1-2 times in a week and walk around his neighborhood to keep him physically active and healthy. He loves dancing as a hobby and going for vacations with his family. The patient reported that he loves to maintain his activities of daily living and dress according to weather, as for his instrumental Activities of Daily Living he said he manages his finances and financial assets by paying his bills early. Mr. R.E loves his traditional African food and occasionally eat out. The patient reported that he keeps to safety measures by putting on his seatbelt and not texting while driving, he also reported having a working smoke detector and a security camera in his house. He has a good family support system for his wife and children. He sleeps 6-8 hours per night.

Family History:

Mr. R.E mother is still alive, age 70, has hypertension and type 2 diabetes mellitus. The Father is still living; he is 72 years old who has asthma.

Maternal grandmother deceased at age 78, had a stroke, she was diabetic.

Maternal grandfather, deceased at age 80, had prostate cancer.

Paternal grandmother deceased at age 70, from chronic obstructive pulmonary disease (COPD)

Paternal grandfather age 95, still alive had asthma.

Brother age 55 has type 2 diabetes mellitus.

Son, age 20, no health issues

Daughter age 16. No health issues.

Daughter 12, no health issues.

General:

The patient is alert and oriented to place, person, time and situation, appropriate judgement, well-nourished black, African American, dressed according to the weather, no distress noted, mild discomfort due to pain in his lower back. Emotional and behavioral needs are appropriate at the present time considering patient clinical condition, no current home stress or abuse.

HEENT: Denies itching eyes or any discharges. The patient said he uses glasses but does not use contact lens, he denies blurred vision. Denies ringing in his ears, hearing loss and discharged. Denies surgery to his ears and any recent infections. Denies epistaxis, discharges, congestion and sneezing, no loss or decreased sense of smell. Denies any sore throat or infection.

Respiratory: Elevated respiratory rate, 30/min. Denies difficulty breathing, coughing, and wheezing. Denies secondhand smoking.

Cardiovascular/Peripheral Vascular: Denies chest pain, heaviness, or heart palpitation, denies shortness of breath and edema to both lower extremities.

Gastrointestinal: No complains of abdominal upset, no nausea or vomiting, have regular bowel movement. No changes in his appetite, no recent weight loss.

Genitourinary: Denies difficulty voiding, changes in voiding pattern and denies any penile discharge.

Neurological: Denies light headedness, fainting, seizure, vision changes or weakness to any side of his body. Denise changes in his thinking.

Skin: Negative for skin lesion, eczema, mole or rash and no skin changes.

Musculoskeletal: Lower back pain that radiates to his left leg. Denies joint stiffness or joint pain.

Hematologic: Denies any bleeding.

Endocrine: Denies cold or heat intolerance, excessive thirst, or urination, does not have any issue with his thyroid.

Psychiatry: Mr. R.E said he is fine, does not have any mental problems, denies depression, suicidal thought, patient states he loves his wife and his family and can never kill himself. Advanced Health Assessment Musculoskeletal Pain

OBJECTIVE DATA:

Physical Examination:

Vital signs: BP 120/80 and regular, Heart rate: 65 and regular, Temperature: 98.2 F orally, Respiration 30; pulse oximetry 95% on room air, Weight: 160 lbs.; Height: 5’ 9”; BMI: 26

Neurological: Patient is alert and oriented to place, person, time and situation, appropriate judgement. Speech is clear, no facial drooping, no vision changes, follows movement. Understand clear, complex, comprehensive without cues or repetition.

Skin: Not pale, cyanosis or ashen. Dry and warm to touch. No tear and non-tainting.

Chest/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 extremities. Capillary refill is less than/equal to 2 seconds in all extremities and no cyanosis noted.

Abdomen: Soft and nondistended, bowel sound present and active in all four quadrants, no pain or rebound tenderness noted. Last Bowel movement was this morning.

Musculoskeletal: Lower back pain radiating to the left lower extremity. No evidence of trauma to affected area. Pain increases with flexion, extension, and twisting. Decreased mobility due to pain.

Diagnostic Tests:

Complete blood count (CBC) may point to infections or inflammation.

Erythrocyte sedimentation rate.

HLA-B27

Bone scans

X-Ray of the lumbar spine

Computerized tomography (CT) cervical spine/lumbar w/without contrast.

MRI of the lumbar spine

Assessment.

Differential diagnoses:

· Lumbar disc herniation (LDH): The intervertebral disc consists of an inner nucleus pulposus (NP) and an outer annulus fibrosus (AF). The central NP is a site of collagen secretion and contains numerous proteoglycans (PG), which facilitate water retention, creating hydrostatic pressure to resist axial compression of the spine. The NP is primarily composed of type II collagen, which accounts for 20% of its overall dry weight. In contrast, the AF functions to maintain the NP within the center of the disc with low amount of PG; 70% of its dry weight is comprised of primarily concentric type I collagen fibers. In LDH, narrowing of the space available for the thecal sac can be due to protrusion of disc through an intact AF, extrusion of the NP through the AF though still maintaining continuity with the disc space, or complete loss of continuity with the disc space and sequestration of a free fragment. It is estimated that this condition has approximately 75% heredity origin, other predisposing factors includes dehydration and Axial Overloading. The role of inflammatory signaling in producing nerve pain in LDH has been well-established. The primary signs and symptoms of LDH are radicular pain, sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots. CT myelography and MRI are used to detect this condition (Amin, R. M., Andrade, N. S., & Neuman, B. J. (2017).

· Lumbar spinal stenosis: Lumbar spinal stenosis is a narrowing of the spinal canal in the lower part of the back. Stenosis, which means narrowing, can cause pressure on the spinal cord or the nerves that go from the spinal cord to the muscles. Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. This condition is most usually categorized as either primary when it is caused by congenital abnormalities or a disorder of the postnatal development, or secondary (acquired stenosis) resulting from degenerative changes or as effects of local infection, trauma, or surgery. Degenerative LSS anatomically can involve the central canal, lateral recess, foramina, or any combination of these locations. Central canal stenosis may result from a decrease in the anteroposterior, transversal, or combined diameter secondary to loss of disc height with or without bulging of the intervertebral disc, and hypertrophy of the facet joints and the ligamentum flavum. Fibrosis is the main cause of ligamentum flavum hypertrophy and is caused by accumulated mechanical stress, especially along the dorsal aspect of the ligamentum flavum. The symptom most ascribed to LSS is neurogenic claudication, also known as pseudoclaudication. Neurogenic claudication refers to leg symptoms containing the buttock, groin, and anterior thigh, as well as radiating down the posterior part of the leg to the feet. In addition to pain, leg symptoms can include fatigue, heaviness, weakness and/or paresthesia. The symptoms can be unilateral or more commonly bilateral and symmetrical. The patient may suffer from accompanying back pain, but leg pain and discomfort are usually more troublesome. (Genevay, S., & Atlas, S. J. (2016). Advanced Health Assessment Musculoskeletal Pain