Description
ASSESSING MUSCULOSKELETAL PAIN Case Study: Ankle PainA 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 (DDx) 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? Instructions: 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.Bear in mind – any musculoskeletal complaint should reflect a mechanism of injury. Specifically indicate how the injury occurred. Additionally, the justification of DDx is not the clinical definition or diagnostic criteria. What are the findings in the note to support the differential diagnosis?Please use a minimum of 3 current resources, including both the school material and outside peer-reviewed resources.
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Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain
S.
CC: “Chest pain”
HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which
began early this morning. The pain is described as “crushing” and is rated nine out of 10 in
terms of intensity. The pain is located in the middle of the chest and is accompanied by
shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with
minimal relief of his symptoms.
Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg
PMH: Positive history of GERD and hypertension is controlled
FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature
cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married
for 39 years
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine
#2 2/23/2021 Moderna
ROS
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity
edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6
systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
© 2021 Walden University
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A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis,
clubbing, noted, positive for bilateral 2+ LE edema is noted.
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
© 2021 Walden University LLC
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LEARNING RESOURCES
Required Readings
•
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.
o Chapter 6, “Vital Signs and Pain Assessment” (Previously read in
Week 6)
o Chapter 22, “Musculoskeletal System”
This chapter describes the process of assessing the musculoskeletal
system. In addition, the authors explore the anatomy and
physiology of the musculoskeletal system.
•
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.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition
by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by
permission of Mosby via the Copyright Clearance Center.
o Chapter 22, “Lower Extremity Limb Pain”Download Chapter 22,
•
•
•
“Lower Extremity Limb Pain”
This chapter outlines how to take a focused history and perform a
physical exam to determine the cause of limb pain. It includes a
discussion of the most common tests used to assess
musculoskeletal disorders.
o Chapter 24, “Low Back Pain (Acute)” Download Chapter 24, “Low
Back Pain (Acute)”The focus of this chapter is the identification of
the causes of lower back pain. It includes suggested physical exams
and potential diagnoses.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA:
F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam”
(“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4,
and 5)
o Chapter 3, “SOAP Notes”
This section explains the procedural knowledge needed to perform
musculoskeletal procedures.
Document: Episodic/Focused SOAP Note Exemplar (Word
document)Download Episodic/Focused SOAP Note Exemplar (Word
document)
Document: Episodic/Focused SOAP Note Template (Word
document)Download Episodic/Focused SOAP Note Template (Word
document)
Required Media
Musculoskeletal System – Week 8 (12m)
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s resources, it is highly recommended that you access and view
the resources included with the course text, Seidel’s Guide to Physical Examination. Focus
on the videos and animations in Chapter 21 that relate to the assessment of the
musculoskeletal system. Refer to the Week 4 Learning Resources area for access
instructions on https://evolve.elsevier.com/Links to an external site.
•
Marquis, P. (2019, April 4). Orthopedic knee evaluation with Paul Marquis
PT [Video].Links to an external
site. YouTube. https://www.youtube.com/watch?v=YVx4BepjjiY&feature=yo
utu.be
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