Posted: October 6th, 2022

Assessing Musculoskeletal Pain

Assessing Musculoskeletal Pain

directions:
After finishing this week’s Practicum Expertise, overview the Complete SOAP Be aware Exemplar and Template on this week’s Sources, and replicate on a affected person who offered with musculoskeletal issues or ache. Describe the affected person’s private and medical historical past, drug remedy and coverings, and follow-up care.

All SOAP notes have to be signed and every web page have to be initialed by your preceptor. While you submit your SOAP Notes, you must embrace the entire SOAP Be aware as a Phrase doc and pdf/pictures of every web page that’s initialed and signed by your preceptor. You will need to submit your SOAP Notes utilizing SAFE ASSIGN.

Assessing Musculoskeletal Pain
Affected person Data:
Initials – SJ Age – 42 Intercourse – M Race – White
S.
CC: Decrease again ache that typically radiates from the left leg.
HPI: 42-year-old male visits to the clinic complaining of decrease again ache. The affected person explains the ache begun one month in the past. He additionally explains that the ache typically radiates from the left leg. He doesn’t state why the ache began. He’s presently taking ibuprofen however with little progress. The ache is affecting his motion. The severity of the ache is 7 out of 10.
Present Drugs:
Ibuprofen 800mg OTC Q4H PRN for every week to alleviate the ache.
Metformin 500mg day by day to decrease blood sugar ranges.
Allergy symptoms:
Allergic to penicillin, not allergic to hay, chilly or mud, and no different allergy symptoms to meals, water, or medication.
PMHx:
Began experiencing decrease again ache one month in the past. She continues to take her remedy for sort 2 diabetes. Diabetes is well-controlled. All vaccines are updated.
Soc Hx:
The affected person works at a neighborhood fitness center. He additionally goes mountaineering over the vacation. The affected person is divorced, however he lives together with his three sons and one daughter who’re 10, 13, 15, and 12 respectively. He isn’t sexually energetic since they separated from his spouse. He denies alcohol consumption or drug abuse. He attends a church service on Sunday at a Catholic church.
Fam Hx:
The affected person’s father died 5 years go after they each succumbed to a coronary heart assault and hypertension. His mom died three years in the past after affected by a stroke. He has three sisters who’re all wholesome. His kids are all wholesome and he has no grandchildren.
ROS:
GENERAL:
No unintentional weight reduction or achieve for the final 12 months. He denies any fever. The affected person complains of decrease again ache that radiates to his left leg.
HEENT: Eyes – He denies of blurred imaginative and prescient or yellow sclera or sensitivity to vibrant mild. He makes use of sun shades since he’s shortsighted. Ears – He denies listening to issues, ache, or discharge from his ears. Nostril – He denies ache, nasal congestion, or working nostril. Throat – He denies any swallowing downside or ache, no tonsil issues or
SKIN: He denies pores and skin rashes, bruises, lesions, itchiness, or dry plaques.
CARDIOVASCULAR: The affected person complains of no discomfort akin to chest tightness, edema, palpitations, and angina.
RESPIRATORY: He denies respiratory issues, coughing, sputum, or shortness of breath.
GASTROINTESTINAL: The affected person denies lack of urge for food, consuming dysfunction, blood within the stool, or diarrhea.
GENITOURINARY: He denies any problem in passing urine or burning sensation.
NEUROLOGICAL: He denies headache, seizures, falls, poor bowel, or bladder management.
MUSCULOSKELETAL: The affected person experiences no damaged bone or fracture or muscle ache. He solely experiences decrease again ache that radiates that typically radiates to the left leg.
HEMATOLOGIC: The sick individual denies bleeding gums, anemia, or bruising.
LYMPHATICS: The affected person doesn’t complain or any tonsils or enlarged lymph nodes.
PSYCHIATRIC: The affected person denies any historical past of tension, insomnia, despair, or suicidal ideas.
ENDOCRINOLOGIC: The affected person denies any extreme sweating at evening, thirst, or pressing must urinate.
ALLERGIES:
Allergic to penicillin, not allergic to hay, chilly or mud, and no different allergy symptoms to meals, water, or medication.
O.
Bodily examination:
Important indicators: Pulse 82, RR 20, Wt 140lbs, T 98.5F, BP 118/90, H 5’9.
Neurological: A, A & O.
Pores and skin: Dry and heat. No lesions, wounds, or rashes.
Lungs: No adventitious sounds or abnormalities. Each lungs are clear.
Cardiovascular: No irregular sounds and has an optimum coronary heart fee.
Stomach: Hyperactive bowel sounds absent and no plenty recognized.
Peripheral vascular: Optimum pulse and no edema.
HEENT: Has no abnormalities.
Musculoskeletal: Decrease again ache that radiates to the left leg. No historical past of arthritis.
Diagnostic Assessments:
The X-ray report will present the place and situation of the backbone. The aim is to find out if the backbone is in the appropriate place. Magnetic Resonance Imaging MRI can be needed to hold out additional Assessment of the herniated lumbar disc (Traeger et al., 2019). MRI can be important to point out overgrown bones or compressed nerves by any herniated disc (Madsbu et al., 2018). Additionally it is important to hold out a CT scan since it’s going to Help rule out a number of the different situations that result in decrease again ache. A number of the situations that result in decrease again ache embrace spinal column harm (Madsbu et al., 2018). Finishing up the three assessments is crucial to evaluate the supply of the decrease again ache by figuring out the situation of the backbone and nerves.
A.
Differential Diagnoses:
The differential analysis of the decrease again will embrace the next situations:
a) Herniated lumbar disc – The herniated lumbar disc is a situation that may result in decrease again ache (Kanat et al., 2017). A herniated disc results in ache as a result of strain on the encircling nerves. The ache can radiate to the left or proper leg. A number of the main signs embrace decrease again ache and physique weak point. It additionally causes problem in motion. One of many main causes of a herniated lumbar disc is strenuous actions (Huliyappa et al., 2017). Suppliers can diagnose the situation utilizing MRI, CT scan, and X-ray for an in depth Assessment of the situation and ruling out doable causes. Herniated lumbar disc is probably the most doable situation the affected person is affected by.
b) Spinal stenosis – Spinal stenosis happens attributable to compression of the nerves because of the narrowing of the spinal twine. A number of the signs embrace ache, numbness, and poor bladder management (Madsbu et al., 2018). Suppliers diagnose the situation utilizing an MRI scan, CT scan, and X-ray.
c) Ankylosing spondylitis – The situation is an inflammatory illness that results in the expansion of small bones on the backbone. Subsequently, the backbone turns into much less versatile. Sufferers hunch ahead attributable to disrupted posture (Namas et al., 2019). It results in decrease again ache. Suppliers diagnose the situation utilizing an MRI scan, CT scan, and X-ray. The experiences ought to present irritation as a result of development of the bones.
d) Sciatica – Sciatica is a well being situation that impacts the sciatica nerves. It is without doubt one of the longest nerves within the physique from the backbone to the legs. If the nerve is compressed or interfered with, it causes irritation and ache. It is without doubt one of the main causes of decrease again ache (Traeger et al., 2019). It happens attributable to spondylolisthesis, muscle spasms, or degenerative backbone (Traeger et al., 2019). The analysis requires an MRI, CT scan, and X-ray. Medical historical past of the affected person and a bodily examination are needed.
e) Muscle pressure – A muscle pressure happens when the muscular tissues are torn or stretched. It happens if an individual is partaking in strenuous actions (Traeger et al., 2019). A number of the main signs embrace ache and swelling. It requires an X-ray for analysis.

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Pupil Signature Date

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Preceptor Signature Date

References
Huliyappa, H. A., Singh, R. Okay., Singh, S. Okay., Jaiswal, M., Jaiswal, S., Srivastava, C., … & Chhabra, S. (2017). Transdural herniated lumbar disc illness with muscle patch for the closure of durotomy–A Temporary overview of the literature. Neurologia i Neurochirurgia Polska, 51(2), 149-155.
Kanat, A., Yazar, U., Ozdemir, B., Kazdal, H., & Balik, M. S. (2017). Uncared for information: Uneven options of lumbar disc illness. Asian Journal of Neurosurgery, 12(2), 199.
Madsbu, M. A., Salvesen, O, Werner, D. A., Franssen, E., Weber, C., Nygaard, P., … & Gulati, S. (2018). Surgical procedure for herniated lumbar disc in day by day tobacco people who smoke: a multicenter observational examine. World Neurosurgery, 109, 581-587.
Namas, R., Hegazin, S. B., Memişoğlu, E., & Joshi, A. (2019). Decrease again ache as a manifestation of acute gouty sacroiliitis: Utilization of dual-energy computed tomography (DECT) in establishing a analysis. European Journal of Rheumatology, 6(four), 216.
Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Prognosis and administration of low-back ache in major care. Cmaj, 189(45), 1386-1395.

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