Description
1. Case Study Chosen: Musculoskeletal
Demographics:
Susan: 30-year-old female
Mary: 70-year-old female
Linda: 45-year-old female
SUBJECTIVE
Susan:
CC: Back pain after helping transfer a patient, difficulty walking
HPI: Recent back injury while assisting a patient transfer, exacerbating an old coccyx fracture, severe pain hindering mobility
Mary:
CC: Backache and right knee pain, worsened by stairs
HPI: Chronic back and knee pain due to osteoarthritis and osteoporosis, exacerbated knee pain affecting daily activities
Linda:
CC: Lower back pain, radiation to right buttock and thigh, numbness
HPI: Chronic lower back pain exacerbated by a recent fall, radiating pain and numbness down the right thigh, disrupting sleep and daily activities
OBJECTIVE
General:
VS: Blood Pressure, Heart Rate, Respiratory Rate, Weight, Height, BMI
Physical Exam Elements: Musculoskeletal examination focusing on the back, lower back, hips, and thighs
ASSESSMENT
Susan:
Working Diagnosis: Acute exacerbation of chronic lower back pain with potential lumbar strain (ICD-10: M54.5)
Differential Diagnosis: Lumbar herniated disc, coccyx fracture complications
Mary:
Working Diagnosis: Osteoarthritis-induced chronic back and knee pain (ICD-10: M15.9, M17.9)
Differential Diagnosis: Degenerative joint disease, exacerbation of osteoporosis-induced fractures
Linda:
Working Diagnosis: Lumbar radiculopathy, likely due to a lumbar disc herniation (ICD-10: M51.16)
Differential Diagnosis: Sciatica, lumbar sprain/strain
PLAN
Susan:
Diagnostic Studies: X-ray of the lumbar spine, if symptoms persist or worsen
Treatment: NSAIDs for pain management (e.g., ibuprofen 800 mg TID), muscle relaxants (e.g., cyclobenzaprine 10 mg TID), physical therapy for rehabilitation
Referrals: Orthopedic specialist for further evaluation if symptoms persist
Education: Proper lifting techniques, importance of calcium intake, smoking cessation strategies
Health Maintenance: Encourage regular exercise and calcium supplementation
RTC: Follow-up in 2 weeks to assess progress and adjust treatment if needed
Mary:
Diagnostic Studies: X-ray of the knee, if pain continues
Treatment: Acetaminophen for pain management (e.g., 650 mg TID), glucosamine/chondroitin supplement continuation, gentle knee exercises, referral to a rheumatologist for further evaluation if pain worsens
Education: Proper joint care, importance of regular exercise, managing acid reflux symptoms
Health Maintenance: Routine bone density scans and Reclast infusions
RTC: Follow-up in 4 weeks to assess progress and adjust treatment if needed
Linda:
Diagnostic Studies: MRI of the lumbar spine for detailed evaluation
Treatment: Consultation with a spine specialist for further evaluation, pain management with NSAIDs (e.g., ibuprofen 800 mg TID), neuropathic pain medication (e.g., gabapentin 300 mg TID), physical therapy for rehabilitation
Referrals: Spine specialist for evaluation and possible intervention
Education: Proper posture and back care, importance of regular exercise
Health Maintenance: Routine back and spine checks
RTC: Follow-up in 2 weeks to assess progress and adjust treatment if needed
American Academy of Orthopaedic Surgeons. (2014). Orthopaedic knowledge update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons.
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross Jr, J. T., Shekelle, P., … & Owens, D. K. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.
National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2021). Osteoarthritis. Retrieved from https://www.niams.nih.gov/health-topics/osteoarthritisLinks to an external site.
Top of Form
Diagnosis
Signs/Symptoms
Gold Standard Diagnostics
Gold Standard Treatment
Low back pain/lumbago
Back pain, limited mobility
Clinical assessment, X-ray, MRI
NSAIDs, physical therapy, exercise, muscle relaxants
Cauda Equina Syndrome
Severe lower back pain, bowel/bladder dysfunction
MRI, myelography
Emergency decompression surgery
Plantar Fasciitis
Heel pain, worsens with activity
Clinical assessment, X-ray, MRI
Stretching exercises, orthotics, physical therapy
Degenerative Joint Disease (Osteoarthritis)
Joint pain, stiffness, limited mobility
Clinical assessment, X-ray, MRI
Pain management (NSAIDs), exercise, physical therapy
Ankylosing Spondylitis
Chronic back pain, morning stiffness, fatigue
Clinical assessment, X-ray, MRI
NSAIDs, physical therapy, biologic medications
Meniscus Tear
Knee pain, swelling, locking or catching of the knee
Clinical assessment, MRI
Physical therapy, arthroscopic surgery
Hip Fracture
Severe hip pain, inability to bear weight
X-ray, CT scan
Surgery (hip replacement, internal fixation)
Pelvic Fracture
Severe pelvic pain, difficulty walking
X-ray, CT scan
Pain management, surgery (internal fixation)
Navicular Fracture
Foot pain, swelling, tenderness
X-ray
Immobilization, non-weight-bearing, possible surgery
Colles Fracture
Wrist pain, deformity
X-ray
Reduction, immobilization (casting), physical therapy
Ankle Sprain
Pain, swelling, limited mobility
Clinical assessment, X-ray
RICE (Rest, Ice, Compression, Elevation), physical therapy
Clinical Pearl
Type of Scan
Indication
Special Considerations
X-ray
Bone fractures/damage, OA, metal, dense objects
–
MRI
Gold standard for injuries to cartilage, meniscus, tendons and ligaments
No metal, pacemakers, aneurysm clips
CT
Views structures like masses, trauma, fractures, bleeding. Forms 3-D picture
More cost-effective than MRI
2. Case Study 1: Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk.” Susan is a healthy young adult, married with a 5-year old. daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she “always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.
Demographics: 30 year old Female
Subjective
CC: Back pain
History of Present Illness (HPI): 30 year old female patient presents with severe back pain after transferring a patient during work. She reports the pain began when she twisted her body to prevent the patient from falling. Patient describes the pain as “terrible” and states she can barely walk.
Past Medical History: Fractured coccyx; no sequelae due to cheerleading fall in teen years. Patient has smoked 1/2 packs of cigarettes everyday for the last 15 years.
Family History: no significant family history
Current Medications: medroxyprogesterone acetate (Depo Provera) injection every 13 weeks. Prescribed calcium but patient states she “always forgets, and it constipates” her
Allergies:
Do you have any allergies to food or medications?
Immunization History:
Are your immunizations up to date? Are you missing any shots?
Social History: Patient is a registered nurse with a husband and a 5 year old daughter
Review of System:
General: Do you have any weakness, fever or chill?
Cardiovascular: Do you have any chest discomfort, heaviness or tightness? Do you feel any abnormal heartbeats or palpitations?
Respiratory: Any shortness of breath? Any coughing or phlegm from your history of smoking?
Gastrointestinal/Genitourinary: Denies any bowel or bladder habit changes
Musculoskeletal: positive for severe back pain making it very difficult to walk. What location do you feel the pain? Does the pain radiate anywhere? How long have you had the pain? On a scale of 0-10 how bad is the pain? Do you have any aggravating or relieving factors: Do you have any associated symptoms such as numbness or tingling? Have you taken any pain relievers?
Objective
Vitals example: BP 118/72, HR 86, RR 16, Spo2 98% on room air, temp 97.1 F Height 5’4 Weight 146 lb, BMI 25.1
Constitutional/general appearance: Vitals stable, Alert, well developed
Respiratory/chest: Unlabored. Chest rise is equal and symmetric. Lungs are CTA bilaterally with no adventitious breath sounds
Cardiovascular: S1,S2 without murmurs, rubs or gallops
GI: bowel sounds present in 4 quadrants. No masses or hernias
Musculoskeletal: positive for tenderness in back and reduced range of motion
Assessment
Working Diagnosis: Acute low back pain (ICD-10: M54.5)
It is estimated that 85% of adults experience lower back pain at some point in their lives. Causes may include strain, sprains, nerve impingement and nerve compression. Acute low back pain was considered the working diagnosis based on the positive reported symptoms of pain after abrupt twisting motion and inability to walk or have full range of motion (See et al., 2021).
Differential Diagnosis:
Sciatica (ICD-10:M54.30)
Patient shows positive signs of Sciatica such as pain in the back that has occurred after injury however she does not report other positive signs such as pain radiating down the back of the leg. Sciatica also typically affects only one side of the body.
Ankylosing Spondylitis (ICD-10: M45.9)
Patient shows positive signs of ankylosing spondylitis such as back pain. The patient’s history of a prior fractured coccyx may cause suspicion of spondylitis however she did not mention if this pain was primarily early morning stiffness or resulted in a stooped posture. Other positive symptoms may include weight loss, fatigue, fever and anemia (Symons, 2012).
Plan
Diagnostic Studies: X-ray
Treatment/ Education
Encourage rest and application of heat to affected area
Avoid heavy lifting or strenuous activity
Education on importance of implementing proper body mechanics in the work environment to prevent future injuries
Start ibuprofen 400 mg every 6 hours as needed for pain x 7 days
Education on the importance of taking calcium supplements. Encourage increase in fluid intake as well as daily fiber intake to prevent constipation.
Education on importance of smoking cessation and offer resources such as nicotine patch (Cho et al., 2021).
