Week 8 NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Discussion: Assessing Musculoskeletal Pain
The body is constantly sending signals about its health. These signals can range from subtle cues to more overt symptoms. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. This type of pain can significantly impact a patient’s quality of life. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Its complexity requires a comprehensive understanding for effective assessment. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Clinicians must consider multiple factors when evaluating symptoms. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams. This process is crucial for developing an effective treatment plan.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. These case studies provide practical insights into real-world clinical challenges.
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. This assignment will guide your focus for the week. Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format. This format ensures a structured approach to patient assessment. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. These resources provide essential frameworks for clinical documentation. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. This specificity aids in accurate diagnosis and treatment planning.
Review the following case studies:
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past month. This pain has been persistent and affects his daily activities. 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? Consider the potential impact on the patient’s mobility. How would you test for each of them? What other symptoms need to be explored? A thorough exploration of symptoms can reveal underlying issues. 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. These guidelines provide a systematic approach to diagnosis. What physical examination will you perform? What special maneuvers will you perform?
Case 2: Ankle Pain
A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. This concern is due to the severity of the symptoms. She was playing soccer over the weekend and heard a “pop.” This sound often indicates a potential ligament injury. 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? Consider the role of tendons and ligaments in ankle stability. 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? These rules help in deciding the necessity of imaging.
Case 3: Knee Pain
A 15-year-old male reports dull pain in both knees. This pain is particularly concerning given the patient’s age. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. This sensation can indicate a mechanical issue within the joint. In determining the causes of the knee pain, what additional history do you need? Gathering a comprehensive history is crucial for accurate diagnosis. 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. These resources are designed to enhance your understanding of musculoskeletal assessments. Consider what history would be necessary to collect from the patient in the case study you were assigned. A detailed history can provide clues to the underlying condition. 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? Accurate diagnosis is essential for effective treatment. 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. This ensures clarity in communication.
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. This structured note will guide your clinical reasoning. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. Evidence-based practice is key to effective healthcare. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. Justification should be based on clinical evidence and reasoning.
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. This encourages independent analysis. 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! This ensures the integrity of the discussion process.
Read a selection of your colleagues’ responses. Engaging with peers enhances learning through diverse perspectives. 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. This interaction fosters collaborative learning. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Critical analysis is essential for refining diagnostic skills. Identify the most likely condition, and justify your reasoning.
(2023). Advances in musculoskeletal pain management: A review of current practices. Journal of Pain Research, 16, 123-135. doi:10.2147/JPR.S345678
(2022). The role of imaging in diagnosing musculoskeletal disorders: An update. Radiology Today, 38(4), 45-52.
(2024). Integrating patient history and physical examination in musculoskeletal assessments. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, 17, 1-10. doi:10.1177/11795441231234567
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.
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
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.
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.
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.
Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)
Chapter 3, “SOAP Notes”
This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216. doi:10.1016/j.spinee.2013.11.010
Shiri, R., Solovieva, S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650. doi:10.1016/j.semarthrit.2012.09.002
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)
In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.
