Assessing Musculoskeletal Pain
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.
Case Study:
A 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 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?
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Solution
Assessing Musculoskeletal Pain: SOAP Note
Student’s Name
Institutional Affiliations
Assessing Musculoskeletal Pain: SOAP Note
Patient Information:
Initials: S. R. Age: 46 years old Sex: Female Race: White
S.
CC: “I have severe pain on my right ankle.”
HPI: Patient S. R. has reported to the clinic complaining of pain in both of her ankles. However, she is more concerned about the pain in her right ankle. The pain has lasted for 3 days. S. R. was playing soccer over the weekend and heard a \”pop.\” She is able to bear weight, but it is uncomfortable. The severity of the pain can pain on her right ankle can be rates at 6/10 on the pain scale.
Current Medications: None
Allergies: No known allergies
PMHx: No major illnesses or surgeries reported. She received all her scheduled immunizations as per her medical records.
Soc Hx: S. R. is married with three children. She neither smokes cigarettes nor drinks alcohol.
Fam Hx: The patient’s father is currently 78 years old and her mother is 70 years old. None of them has been diagnosed with a chronic condition. None of the patient’s siblings has been diagnosed with a rare disease.
ROS:
General: No fever, chills, or significant weight loss.
HEENT: Head: No head injury reported. Eyes: No blurred vision or visual loss. Ears: No pain, no hearing loss, no discharge. Nose: Sensitive to smell, no congestion, no runny nose. Throat: No sore throat.
Respiratory: No breathing issues reported.
Cardiovascular: Denies shortness of breath and tightness of the chest.
Musculoskeletal: Reports severe pain and discomfort on her right ankle.
Allergies: Denies a history of asthma.
O.
Physical Exam:
Vital signs: Weight=92.4 lb., BMI=23.4, Temperature= 35.7 degrees Celsius, respiratory rate=17 breaths per minute.
General: S. R. maintains eye contact, attentive, and responds to questions.
Musculoskeletal: The patient feels extreme pain at the right ankle joint on touching.
Diagnostics: X-ray, Magnetic Resonance Imaging (MRI).
ASSESSMENT:
Differential Diagnoses:
- Ankle sprain
- Subtalar dislocation
- Ankle fracture
Primary diagnosis: Ankle sprain
References
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.
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.
Melanson, S. W., & Shuman, V. L. (2020). Acute ankle sprain. Treasure Island (FL): StatPearls Publishing.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.