The body is constantly sending signals about its health. One of the most easily recognized signals is pain
Discussion: Assessing Musculoskeletal Pain
Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
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.
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.
Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
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? CORE SKILL: building a musculoskeletal differential from the pattern of joint involvement. The PATTERN is the diagnosis — count the joints, note the symmetry, and time the stiffness.
THE THREE QUESTIONS THAT DO MOST OF THE WORK:
1. HOW MANY JOINTS? Monoarticular (think septic arthritis, gout, trauma, hemarthrosis) vs. oligoarticular (2–4) vs. polyarticular (≥5 — think RA, SLE, viral).
2. SYMMETRIC OR ASYMMETRIC? RA is symmetric and involves the small joints (MCP, PIP — and characteristically SPARES the DIP). Osteoarthritis is asymmetric, weight-bearing, and involves the DIP (Heberden’s nodes) and PIP (Bouchard’s nodes). That DIP/MCP distinction alone separates the two most common arthritides.
3. INFLAMMATORY OR MECHANICAL? INFLAMMATORY: morning stiffness lasting >60 minutes, IMPROVES with use, worse with rest, warmth/swelling/erythema, systemic symptoms, elevated ESR/CRP. MECHANICAL/DEGENERATIVE: stiffness <30 minutes, WORSENS with use, improves with rest, minimal systemic features. This is the single most useful discriminator in rheumatology and it comes entirely from the history.
THE ONE YOU CANNOT MISS: SEPTIC ARTHRITIS — acute monoarticular, hot, exquisitely painful joint with fever and refusal to move it. It destroys cartilage within days. ARTHROCENTESIS IS MANDATORY before starting antibiotics. Know synovial fluid analysis: non-inflammatory WBC 50,000 with >90% PMNs; and crystal analysis under polarized light — GOUT = needle-shaped, NEGATIVELY birefringent (yellow when parallel); PSEUDOGOUT (CPPD) = rhomboid, POSITIVELY birefringent. Note that gout and septic arthritis can COEXIST, so a positive crystal finding does not exclude infection.
OTHER KEY ENTITIES: gout (podagra — first MTP joint, purine/alcohol/diuretic triggers, hyperuricemia — though serum urate can be NORMAL during an acute flare, a classic exam trap); polymyalgia rheumatica (age >50, proximal shoulder/hip girdle pain and stiffness, markedly elevated ESR, dramatic steroid response — and always ask about temporal headache/jaw claudication/visual change because of its association with GIANT CELL ARTERITIS, which threatens vision and is treated emergently); fibromyalgia (widespread pain, fatigue, non-restorative sleep, NORMAL inflammatory markers — a diagnosis of central sensitization, not inflammation); ankylosing spondylitis (young male, inflammatory back pain, HLA-B27).
EXAM: inspect, palpate for warmth/effusion/tenderness, active then passive ROM, joint-specific special tests (McMurray, Lachman, drawer, Phalen, Tinel, Finkelstein).
DIAGNOSTICS: know what each test actually adds — RF is neither sensitive nor specific; ANTI-CCP is far more SPECIFIC for RA; ANA is sensitive but poorly specific for SLE (a good screen, a bad confirmation).
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