Musculoskeletal Assignment Discussion Paper

Musculoskeletal Assignment Discussion Paper

You are working with Dr. Lee today. She hands you a triage note from the nurse regarding your next patient, Mr. Payne: Forty-five-year-old white male truck driver complaining of two weeks of sharp, stabbing back pain after lifting a 10-lb. box. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed. Dr. Lee provides you some background information about low back pain. Dr. Lee continues: “There are many causes for LBP. For presenting symptoms that have a broad differential diagnosis, I find it helpful to think of systems of etiologies in which diseases or conditions can be categorized.” You and Dr. Lee take a few minutes to review Mr. Payne’s chart: Vital signs: • • • • • • Temperature: 98.6° Fahrenheit Heart rate: 80 beats/minute Respiratory rate: 12 breaths/minute Blood pressure: 130/82 mmHg Weight: 170 pounds Body Mass Index: 24 kg/m2 Past Medical History: Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control. Past Surgical History: None Social History: Works as a truck driver, which involves lifting 20-35 lbs 4 hours of the day, married with 2 daughters, Habits: Musculoskeletal Assignment Discussion Paper

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Smoked one pack per day for 20 years. Quit smoking two years ago, drinks one to two beers occasionally on the weekends, no history of IV drug use. Medication: • • • • • Metformin 1000mg PO twice daily Glyburide 10mg PO twice daily Amlodipine 2.5 mg PO daily Lisinopril 40 mg PO daily Simvastatin 40 mg PO daily Allergies: No known drug allergies. After introducing yourself to Mr. Payne, you sit down across from him and begin your history, focusing on the key elements. “Can you tell me about your back pain?” “As I told the nurse, the pain started two weeks ago after I lifted a box at work. Right away, I got this sharp pain on the left side of my back. The box wasn’t even that heavy. “I talked to the nurse at work; she said to ice it and to take ibuprofen. It got better after three days. But, I was playing softball with my daughter last weekend, and the pain came back. This time it was worse than before and became constant. This week, the pain is so bad I can hardly get out of bed. I get a sharp pain in my back which goes down my left leg to my ankle.” “On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain, how severe is the pain?” “It’s probably a 7.” “Have you found anything that improves the pain?” “Ibuprofen and Naproxen worked at first, but they are not helping much anymore.” “What dose of ibuprofen and naproxen were you taking, how often, and for how many days?” “I was taking ibuprofen 400 mg every six hours for three days and then I tried naproxen 250 mg once daily for five days.” “What about positions that make things better or worse?” “The pain is worse with any movement of my back or sitting for a long time. It is better when I lie down.” “Have you had back pain before?” “Yes, I have back pain from time to time. But I’m usually better after 2 to 3 days. This is the worst pain I have ever had.” You complete your history with a review of systems and discover: Mr. Payne is a 45-year-old male truck driver with a two-week history of low back pain that radiates down his left leg to the ankle. The pain is worse with sitting and improves with the supine position. He denies history of trauma, fever/chills, night pain, urinary symptoms, and bowel or bladder incontinence. The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes: 1. Epidemiology and risk factors: 45-year-old male; occupation: truck driver 2. Key clinical findings about the present illness using qualifying adjectives and transformative language: • • • • • • • • • • pain present for two weeks pain radiates down left leg pain worse with sitting and improves with supine position no history of trauma no fever/chills no night pain no urinary symptoms no bowel or bladder incontinence Dr. Lee tells you, “On physical exam, you can discover problems with the bony structures and muscles of the spine through inspection of posture, contour, and symmetry, palpation of the bony prominences, and range of motion testing. A solid understanding of the neurological exam of the lower extremity will help you determine if the pain is due to nerve impingement or from muscle and bone.” You and Dr. Lee return to examine Mr. Payne together. Perform the back exam systematically in sequential order with the patient: 1. Standing 2. Sitting 3. Supine 4. Dr. Lee walks through the steps for completing a neurologic exam in a patient with back pain. 5. Back Exam – Standing: 6. Mr. Payne has normal curvature, tenderness on palpation on the left lumbar paraspinous muscle with increase tone. Full range of motion, but has pain with movement. His gait is normal. He can walk on his heels and toes. He can do deep knee bends. 7. Back Exam – Seated: 8. Mr. Payne reports no pain when checked for CVA tenderness. He has no pain in his right leg with the modified version of SLR. While he does not exhibit a true tripod sign, he does complain of pain when his left leg is raised. Mr. Payne’s reflexes are 2+ and equal at the knees and 1+ at both ankles. The motor exam reveals 5/5 strength throughout the lower extremities. His sensory exam is normal. 9. Pulmonary Exam: His lungs are clear. 10. Musculoskeletal Assignment Discussion Paper

Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or gallop. Physical Exam for Back Pain – Seated Position Overview of the Neurologic Exam Deep Tendon Reflexes Grading Reflexes: 0 No evidence of contraction 1+ Decreased, but still present (hyporeflexic) 2+ Normal 3+ Increased (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation Decreased patella reflex implies nerve impingement at the L3-L4 level. Decreased Achilles reflex implies nerve impingement of S1 levels. Hyper-reflexia is a sign of upper-motor neuron syndrome associated with spinal cord compression. Muscle Strength Rating Scale: 0/5 No movement 1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it’s attached. 2/5 Voluntary movement, which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface. 3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. 4/5 Voluntary movement capable of overcoming “some” resistance 5/5 Normal strength i. Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you push down on his thigh ii. Hip Abduction (L 4, 5, S1): Ask the patient to push his legs apart while you push them together iii. Hip Adduction (L 2, 3, 4): Ask the patient to push his legs together while you push them apart iv. Knee Extension (L 2, 3, 4): Ask the patient to extend their knee while you push it down. v. Knee Flexion (L 5, S1, S2): Ask the patient to flex his knee while you push against it. vi. Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up while you push it down. vii. Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot down while you push it up. Decreased strength implies nerve impingement of the associated nerve in parenthesis. Sensation Test for sharp and light touch along dermatomal distribution, great toe (L5), lateral malleolus, and posteriolateral foot (S1) Nerve Root Impingement Syndromes Nerve Root L3 L4 L5 S1 Reflex Pin-Prick Sensation Patellar tendon reflex Patellar tendon reflex Medial hamstring Achilles tendon reflex Lateral thigh and medial femoral condyle Medial leg and medial ankle Lateral leg and dorsum of foot Posterior calf, Sole of foot, and lateral ankle Motor Examination Extend quadriceps Functional Test Squat down and rise Dorsiflex ankle Walk on heels Dorsiflex great toe Walk on heels Stand on toes Walk on toes (plantarflex ankle) Check for costovertebral angle (CVA) tenderness, a sign suggesting pyelonephritis. Modified version of the straight leg raise (SLR) test While continuing to talk to the patient, raise each leg by extending the knee from 90 degrees to straight. If the pain is due to structural disease, the patient will instinctively exhibit the “tripod sign” by leaning backward and supporting himself with his outstretched arms on the exam table. (The unmodified version of the straight leg raise (SLR) test is done in the next section of the exam with the patient supine.) Neurological exam Check reflexes, muscle strength, and sensation of the lower extremities. Focus on the L4, L5, and S1 nerve roots because most neuropathic back pain is due to impingement of these. Therefore, check the patellar reflex (L2-4) and Achilles reflex (S1). Check muscle strength for hip flexion, abduction, and adduction; knee extension and flexion; as well as ankle dorsiflexion and plantar flexion. Also, test for sharp and light touch along the dermatomal distribution of the great toe (L5), lateral malleolus and posterolateral foot (S1). Dr. Lee continues, “The final part of the exam is done in the supine position.” Exam – Supine Mr. Payne’s abdominal exam is negative. His straight leg raising is positive at 75 degrees on the left and negative on the right. His FABER test is negative and sacroiliac joint is nontender.

His motor exam reveals no weakness of the muscles of the lower extremities Disc herniation, Lumbar strain Based on physical exam, you believe that Mr. Payne has back pain with radiculopathy, likely at the L5/S1 level. Given his risk factor as a truck driver and pain radiating down his leg, Mr. Payne’s pain is likely due to disc herniation. However, lumbar strain is still a possibility. Dr. Lee reminds you that disc herniation, a condition which is self-limited and usually resolves in two to four weeks, remains a working diagnosis for Mr. Payne. She says, “Let’s take a few minutes, though, to discuss some conditions we still don’t want to miss.” While Dr. Lee takes the time to return to the exam room and review mechanical low back pain with Mr. Payne, she asks you to to consider what other testing should be done at this time. Is an MRI indicated? Musculoskeletal Assignment Discussion Paper

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