Musculoskeletal Focused Note Discussion Paper
For this Assignment, you will work with a patient with a musculoskeletal condition that you examined during the last three weeks. You will complete your third Episodic/Focused Note Template Form for this course where you will gather patient information, relevant diagnostic and treatment information as well as reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, previous medical history (PMH), socio-economic, cultural background, etc. In this week’s Learning Resources, please review the Focused Note resources for guidance on writing Focused Notes. Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN. Note: Electronic signatures are not accepted. Musculoskeletal Focused Note Discussion Paper
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If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. To prepare: Use the Episodic/Focused Note Template found in the Learning Resources for this week to complete this assignment. Select a patient that you examined during the last three weeks based on musculoskeletal conditions. With this patient in mind, address the following in a Focused Note: Assignment: Subjective: What details did the patient provide regarding her personal and medical history? Objective: What observations did you make during the physical assessment? Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Reflection notes: What would you do differently in a similar patient evaluation? Musculoskeletal Focused Note Discussion Paper
Episodic/Focus Note Template
Patient Information:
MT, 57, Female, Hispanic.
S.
CC “Neck pain on the right side”
HPI: MT is a 57 year old female presenting today for follow up right sided neck pain and desires PT referral. She reports that she pulled a muscle 5 weeks while cleaning her house. She felt the pain while pushing a wet mop. She describes the pain as a tight pain that radiates to both shoulders and right arm. The pain worsens with movement of her right arm. She reports some numbness “my arm is asleep” in her right arm at times. The numbness is relieved by repetitive rotation of her right wrist. She does not have numbness all the time. She denies weakness or tingling. She reports that Zanaflex, ibuprofen, and heat/cold therapy help the pain but does not completely take the pain away. She reports a hx of stomach ulcers for the first time today. She rates her pain now 6/10.
Current Medications: Tizanidine (Zanaflex) 2 mg daily 1 tablet every 8 hours as needed for spasm. Fluticasone (Flovent) 110MCG/ACT 1 puff 2 times daily. Albuterol 108(90) base 2 puffs Q6 hours as needed PRN. Vitamin D 2000 units daily Musculoskeletal Focused Note Discussion Paper
Allergies: No known allergies
PMHx: Intermittent Asthma, subclinical hyperthyroidism, headache, tubal ligation. Tdap 2018.
Soc Hx: Married lives with her husband. She does not smoke or drink alcohol. She wears her seatbelts all the time, has working smoke detectors. Feels safe at home and no Domestic violence concerns. No distracting driving.
Fam Hx: Mother alive with diabetes, HTN, hyperlipidemia. Father: deceased- lung cancer, brain tumor. Sister: alive with diabetes. Brother: alive with diabetes. 3 daughters- healthy. 1 son- healthy. 2 grandchildren.
ROS.
GENERAL: No fatigue, malaise, fever, chills night sweats or unexplained weight loss.
HEENT EYES: clear sclera, no blurry or double vision or eye pain. Ears, Nose, Throat: no ear pain, no runny nose or nasal congestion, no sore throat.
SKIN: No rash, dryness or itching.
CARDIOVASCULAR: No palpitations, tachycardia, Chest pain, dyspnea, or lower extremity edema.
GASTROINTESTINAL: No poor appetite, nausea, heartburn, Abd pain, black or bloody stools.
GENITOURINARY: No urinary symptoms. No unusual vaginal discharge, itching or odor. Post-menopausal- no abnormal bleeding Musculoskeletal Focused Note Discussion Paper
NEUROLOGICAL: no headache, dizziness, confusion, weakness, speech problems, gait or balance problems. No numbness or tingling.
MUSCULOSKELETAL: no muscle weakness, stiffness, swollen or painful joints.
HEMATOLOGIC: no easy bruising or bleeding
LYMPHATICS: No enlarged or painful lymph nodes.
PSYCHIATRIC: no sleep disturbance, anxiety, depression or suicidal thoughts.
ENDOCRINOLOGIC: No heat or cold intolerance. No polyuria or polydipsia.
ALLERGIES: Hx of asthma. No eczema or hives.
O.
Physical exam:
VS: 105/60 65 20 97.7 100% Ht 5’3” Wt 135 lbs. BMi 27.
General: Appears well. NAD.
HEENT: Head Normocephalic. Eyes: sclera clear. Ear: Normal, symmetrical, Tympanic membrane visualized. Nose: nares patent. Throat: no redness or swelling noted. Neck: supple, no lymphadenopathy, thyroid not enlarged Musculoskeletal Focused Note Discussion Paper
RESP: Lung sounds clear to auscultation without rales, rhonchi or wheezing.
CV: regular rhythm, normal sounds S1 S2 and absence of murmurs, rubs, or gallops. No edema.
GI: positive bowel sounds in all quadrants, soft non tender without evidence of organomegaly or masses. No guarding.
MSK: ambulates without difficulty. No obvious deformity. No lower extremity edema.
NEURO: A+OX4. 5/5 strength in upper and lower extremities, unremarkable reflexes, normal gait. No focal deficits appreciated.
Diagnostic results: no diagnostic tests done.
A.
Based on the subjective and objective data obtained, the possible diagnoses include:
- Cervical radiculopathy
- Muscle strain
- Brachial plexus injury
The primary diagnosis is cervical radiculopathy because the patient describes the pain as a tight pain that radiates to both shoulders and right arm and the pain worsens with movement of her right arm. The patient also reports experiencing some occasional numbness in her right arm that is relieved by repetitive rotation of her right wrist. Cervical radiculopathy develops when a nerve in the neck is crushed or inflamed at the point where it branches out from the spinal cord (Iyer & Kim, 2016). This can result in shoulder pain, as well as muscular weakness and numbness that goes down the arm and into the hand.
The primary diagnostic test to be performed at this point is MRI. MRI provides more accurate imaging of the body’s soft tissues. Damage to soft tissues, including a herniated or a bulging disk, may lead to nerve compression, and an MRI of the neck can reveal if this has occurred (Iyer & Kim, 2016). It may also assist in determining if your spinal cord or nerve roots have been damaged. Furthermore, the foraminal compression test (also known as the Spurling test) is one of the most effective tests for establishing the diagnosis of cervical radiculopathy. It is carried out by situating the patient with the neck stretched and the head rotated, and then exerting downward pressure on the patient’s head with the fingers Musculoskeletal Focused Note Discussion Paper
Cervical radiculopathy may be effectively treated using physical therapy techniques. In many situations, physical treatment is able to fully eliminate the symptoms. Specific exercises may aid in the relief of pain, the strengthening of neck muscles, and the improvement of range of movement. Traction is a technique that may be used to gently extend the muscles and joints of the neck (Romeo et al., 2018). Discomfort relief from neck pain will also need pharmacological intervention in the form of Nonsteroidal anti-inflammatory drugs (NSAIDs) (Corey & Comeau, 2017). Aspirin, ibuprofen, and naproxen are examples of nonsteroidal anti-inflammatory drugs (NSAIDs) that may give relief from nerve inflammation or irritation. Oral corticosteroids may also be effective in relieving pain by decreasing stiffness and irritation surrounding the nerve. Rest and activity modification will be used as alternative therapy. Restriction of vigorous activities, such as sports or carrying heavy items, as well as improved posture when sitting or driving, may help to alleviate the symptoms (Corey & Comeau, 2017). The patient should follow up in four weeks to determine if the symptoms will have disappeared.
Reflecting on this case, I agree with the preceptor’s treatment of the patient because I believe it was a perfect demonstration of how to provide care for patients with neck pain. In this particular case, I learnt that alternative therapies like rest and activity modification are essential in treating musculoskeletal problems as they aim at alleviating symptoms. There is nothing I would do differently because I believe this a comprehensive approach to treatment of a patient with a musculoskeletal problem. I would therefore do the same in the future. In regard to health promotion, radiculopathy cannot always be avoided, but remaining physically active and having a healthy weight will help to lower your chances of developing the condition in the future. Using best practices for excellent posture when sitting, performing household chores, playing sports, exercising or carrying heavy things is also useful for preventing injuries. It is also essential to take into consideration patient factors associated with cervical radiculopathy such as white race, tobacco consumption, and a history of lumbar radiculopathy. Musculoskeletal Focused Note Discussion Paper
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References
Corey, D. L., & Comeau, D. (2017). Cervical Radiculopathy. Medical Clinics of North America, 98(4), 791-799. https://doi.org/10.1016/j.mcna.2014.04.001
Iyer, S., & Kim, H. J. (2016). Cervical radiculopathy. Current Reviews in Musculoskeletal Medicine, 9(3), 272-280. https://doi.org/10.1007/s12178-016-9349-4
Peng, B., & DePalma, M. J. (2018). Cervical disc degeneration and neck pain. Journal of pain research, 11, 2853–2857. https://doi.org/10.2147/JPR.S180018
Romeo, A., Vanti, C., Boldrini, V., Ruggeri, M., Guccione, A. A., Pillastrini, P., & Bertozzi, L. (2018). Cervical Radiculopathy: Effectiveness of adding traction to physical therapy—A systematic review and meta-analysis of randomized controlled trials. Physical Therapy, 98(4), 231-242. https://doi.org/10.1093/physth/pzy001
Episodic/Focus Note Template
Patient Information:
MT, 57, Female, Hispanic.
S.
CC “Neck pain on the right side”
HPI: MT is a 57 year old female presenting today for follow up right sided neck pain and desires PT referral. She reports that she pulled a muscle 5 weeks while cleaning her house. She felt the pain while pushing a wet mop. She describes the pain as a tight pain that radiates to both shoulders and right arm. The pain worsens with movement of her right arm. She reports some numbness “my arm is asleep” in her right arm at times. The numbness is relieved by repetitive rotation of her right wrist. She does not have numbness all the time. She denies weakness or tingling. She reports that Zanaflex, ibuprofen, and heat/cold therapy help the pain but does not completely take the pain away. She reports a hx of stomach ulcers for the first time today. She rates her pain now 6/10. Musculoskeletal Focused Note Discussion Paper
Current Medications: Tizanidine (Zanaflex) 2 mg daily 1 tablet every 8 hours as needed for spasm. Fluticasone (Flovent) 110MCG/ACT 1 puff 2 times daily. Albuterol 108(90) base 2 puffs Q6 hours as needed PRN. Vitamin D 2000 units daily.
Allergies: No known allergies
PMHx: Intermittent Asthma, subclinical hyperthyroidism, headache, tubal ligation. Tdap 2018.
Soc Hx: Married lives with her husband. She does not smoke or drink alcohol. She wears her seatbelts all the time, has working smoke detectors. Feels safe at home and no Domestic violence concerns. No distracting driving.
Fam Hx: Mother alive with diabetes, HTN, hyperlipidemia. Father: deceased- lung cancer, brain tumor. Sister: alive with diabetes. Brother: alive with diabetes. 3 daughters- healthy. 1 son- healthy. 2 grandchildren.
ROS.
GENERAL: No fatigue, malaise, fever, chills night sweats or unexplained weight loss.
HEENT EYES: clear sclera, no blurry or double vision or eye pain. Ears, Nose, Throat: no ear pain, no runny nose or nasal congestion, no sore throat.
SKIN: No rash, dryness or itching.
CARDIOVASCULAR: No palpitations, tachycardia, Chest pain, dyspnea, or lower extremity edema.
GASTROINTESTINAL: No poor appetite, nausea, heartburn, Abd pain, black or bloody stools.
GENITOURINARY: No urinary symptoms. No unusual vaginal discharge, itching or odor. Post-menopausal- no abnormal bleeding.
NEUROLOGICAL: no headache, dizziness, confusion, weakness, speech problems, gait or balance problems. No numbness or tingling.
MUSCULOSKELETAL: no muscle weakness, stiffness, swollen or painful joints.
HEMATOLOGIC: no easy bruising or bleeding
LYMPHATICS: No enlarged or painful lymph nodes.
PSYCHIATRIC: no sleep disturbance, anxiety, depression or suicidal thoughts.
ENDOCRINOLOGIC: No heat or cold intolerance. No polyuria or polydipsia.
ALLERGIES: Hx of asthma. No eczema or hives. Musculoskeletal Focused Note Discussion Paper
O.
Physical exam:
VS: 105/60 65 20 97.7 100% Ht 5’3” Wt 135 lbs. BMi 27.
General: Appears well. NAD.
HEENT: Head Normocephalic. Eyes: sclera clear. Ear: Normal, symmetrical, Tympanic membrane visualized. Nose: nares patent. Throat: no redness or swelling noted. Neck: supple, no lymphadenopathy, thyroid not enlarged.
RESP: Lung sounds clear to auscultation without rales, rhonchi or wheezing.
CV: regular rhythm, normal sounds S1 S2 and absence of murmurs, rubs, or gallops. No edema.
GI: positive bowel sounds in all quadrants, soft non tender without evidence of organomegaly or masses. No guarding.
MSK: ambulates without difficulty. No obvious deformity. No lower extremity edema.
NEURO: A+OX4. 5/5 strength in upper and lower extremities, unremarkable reflexes, normal gait. No focal deficits appreciated.
Diagnostic results: no diagnostic tests done.
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A.
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)Musculoskeletal Focused Note Discussion Paper.
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.
Peng, B., & DePalma, M. J. (2018). Cervical disc degeneration and neck pain. Journal of pain research, 11, 2853–2857. https://doi.org/10.2147/JPR.S180018 Musculoskeletal Focused Note Discussion Paper