Muscoskeletal Focused Note Discussion Paper

Episodic visit: Musculoskeletal Focused Note

Student Name

Program Name, Institution

COURSE CODE: Course Title

Instructor Name

Date

Episodic visit: Musculoskeletal Focused Note

Patient Information:

T.J, 28 years old, African-American female

S.

CC (chief complaint) I have a lot of pain in my lower back that makes it hard to get things done and It doesn’t seem to be going away

HPI: Ms. Jones comes to the clinic with back pain that started three days earlier when she “tweaked” it when helping a friend carry a large crate. She claims she had raised many boxes without issue prior to this case and has no idea which weigh box triggered her discomfort. Her low back and bilated buttocks are aching with discomfort, and the agony does not radiate. Sitting makes the discomfort worse (7/10), while lying flat on her back makes it better (3-4/10). The discomfort hasn’t improved in three days, and she’s been treating it with both over-the-counter ibuprofen medication every 5-6 hours. Her present pain level is a 5/10, although she claims that ibuprofen will reduce it to a 2-3/10. She experiences numbness, twitching, muscle fatigue, and incontinence of the bowels or bladder. She is reporting today because the discomfort has persisted and is interfering in her everyday tasks Muscoskeletal Focused Note Discussion Paper

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.Location: Lower back

Onset: 3 days ago

Character: Difficulty in motion

Associated signs and symptoms: numbness, tingling, muscle weakness, bowel or bladder incontinence

Timing: sitting for long hours

Exacerbating/ relieving factors: Lying down flat on the back

Severity: 7/10 pain scale

Current Medications: Metformin, 850 mg PO BID

Albuterol 90 mcg/spray MDI 2 puffs Q4H

Ibuprofen 600 mg PO TID

Allergies: allergic to cats and dust. Also allergic to penicillin

PMHx: Diagnosed with Asthma at age 2 1/2. Her last hospitalized for asthma was when she was in high school. She has a history of hypertension which she manages by exercise and eating healthy. She was diagnosed with diabetes at the age of 24. No past surgical history. Her LMP was 2 weeks ago

Soc Hx: Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single-family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin Muscoskeletal Focused Note Discussion Paper

Fam Hx: Mother: age 50, hypertension, elevated cholesterol. 

Brother 25: overweight.

Sister, 14: asthma.

Maternal grandmother: stroke, hypertension, high

cholesterol.

ROS:

GENERAL: Denies chills, weight loss, fever, night sweats or fatigue

HEENT: Eyes: Denies visual loss or blurred vision.. Denies hearing problems and sinus pain. Denies sore throat

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies palpitations, edema, chest pain or pressure

RESPIRATORY: Denies shortness of breath, cough, and sputum production.

GASTROINTESTINAL: Denies abdominal pain. Diarrhea nausea or vomiting

GENITOURINARY: Denies frequency of urination

LMP-2 weeks ago.

NEUROLOGICAL: Denies dizziness, migraine or syncope.

MUSCULOSKELETAL: Pain in the lower back. She states that she has problems moving. Denies muscle pain or weakness.

HEMATOLOGIC: No bruising, anemia or bleeding.

LYMPHATICS: No swollen or enlarged lymph nodes.

PSYCHIATRIC: Denies history of anxiety or depression.

ENDOCRINOLOGIC: Denies sweating, heat intolerance or cold. No polyuria or polydipsia.

ALLERGIES: History of Asthma

O.

GENERAl: The patient is alert and oriented with no acute distress. She maintains eye communication throughout the examination.

HEENT: No edema. Head symmetrical without lesions. Conjuctiva is pink with no discharge. Ears symmetrical, with no discharge. Throat moist, without exudate.

SKIN: No rash or itching

CARDIOVASCULAR: No palpitations, edema, chest pain or pressure

RESPIRATORY: Lungs clear to auscultation. Chest is symmetric with respiration

GASTROINTESTINAL: Normoactive bowel sounds. Soft and non-tender

GENITOURINARY: No urination problems

NEUROLOGICAL: Normal stereognosis and graphesthesia. Strength 5/5 bilateral upper and lower extremities. Tests of cerebellar function normal.

MUSCULOSKELETAL: Bilateral upper extremities without joint deformity. Normal range of motion

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Diagnostic results 

Computed tomography (CT)- No tumors or lesions.

Prolactin 18

CBC: hgb 10.1 hct 30.1

Platelets 21

A.

Low back muscle strain related to lifting- A muscle strain is an instant injury that affects a tendon, joint, or ligament. These incidents commonly happen as a result of jarring collisions or movements that involve hard lifting or putting too much weight on the spine. Low back discomfort is caused by heavy lifting, stretching the spine, moving from the ground, or carrying an object overhead (Suehiro et al., 2018). Lifting techniques such as holding the object tight to the chest while not bending the upper body when lifting are examples of safe lifting techniques.

Herniated disc pain- An issue with one of the stringy cushions (disks) that lie in between compact bone (vertebrae) that mount to create the spine is referred to as a herniated disk (Dulebohn & Mesfin, 2017). The core of a spinal disk is wrapped in a thicker, rubbery coating. A herniated disk, also known as a slipped or punctured disk, happens when part of the nucleus moves forward through a crack in the annulus. A herniated disk may irritate a surrounding nerve if it occurs in some section of the spine. A herniated disk may cause discomfort, numbness, or fatigue in an arm or leg, based on where it is located. The patient’s pain being caused by heavy lifting could be a likeliness of Hearniated dic. Muscoskeletal Focused Note Discussion Paper

Acute mechanical back pain: Mechanical back pain, also known as acute back pain, is a widespread medical condition. Acute pain is described as back discomfort that lasts less than 4 to 6 months (Will et al., 2018). The cause of the discomfort in the spinal nerves , discs, vertebral column, or connective tissue. Acute mechanical back pain, also known as lumbago, psychogenic low back pain, lumbar strain or ligament, or lumbar disorder, is a type of acute low back pain.

Referrals: No referrals required at this time

Therapeutic interventions:

  • Ibuprofen 600 mg by mouth every six to eight hours
  • Acetaminophen 500-1000 mg by mouth eight hours
  • Exercise regularly.
  • Eat a balanced diet rich in fiber and iron.

Patient education:

  • Educate the patient on need for mediation adherence and the possible adverse effects (Jin-Sung Kim, 2016).
  • Also educate on the need for consuming balanced diet and exercising regularly.

Disposition:

  • Within four weeks, the client should return to the hospital for a re-evaluation of his or her symptoms.

Health Promotion: Advise the patient on the need for avoiding heavy lifting.

Reflection: The musculoskeletal examination of Ms. Jones’ concerns is deemed successful because the questions posed, the facts gathered, and the preparation approaches used reflected sound analytical thought and professional decision making by assisting in the pursuit of several different paths for various reasons, the exploration of complex concepts, and the uncovering of issues, both of which lead to adequate preparation and symptom management (Will et al., 2018). She was diagnosed with low back muscle strain related to lifting. The analysis was comprehensive and exhaustive hence there is nothing I would have done differently

References

Alkhatib, B., Rosenzweig, D., Krock, E., Roughley, P., Beckman, L., Steffen, T., Weber, M., Ouellet, J., & Haglund, L. (2014). Acute mechanical injury of the human intervertebral disc: Link to degeneration and pain. European Cells and Materials, 28, 98-111. https://doi.org/10.22203/ecm.v028a08

C., & Mesfin, F. B. (2017). Disc herniation. https://doi.org/10.1016/b978-0-323-48554-8.50106-8

Jin-Sung Kim, M. D. (2016). Percutaneous endoscopic lumbar discectomy as an alternative to open lumbar microdiscectomy for large lumbar disc herniation. Pain physician, 19, E291-E300.

Suehiro, T., Ishida, H., Kobara, K., Osaka, H., & Watanabe, S. (2018). Altered trunk muscle recruitment patterns during lifting in individuals in remission from recurrent low back pain. Journal of Electromyography and Kinesiology, 39, 128-133. https://doi.org/10.1016/j.jelekin.2018.02.008

Will, J. S., Bury, D. C., & Miller, J. A. (2018). Mechanical low back pain. American family physician, 98(7), 421-428. https://doi.org/10.5040/9781350984639 Muscoskeletal Focused Note Discussion Paper

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance) Muscoskeletal Focused Note Discussion Paper.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

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SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis Muscoskeletal Focused Note Discussion Paper.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

A.

Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).

References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Muscoskeletal Focused Note Discussion Paper