Focused SOAP Note: Assessing Musculoskeletal Pain Example

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.

Focused SOAP Note: Assessing Musculoskeletal Pain

Patient Information

Name: JD

Age: 46 years

Sex: female

Race: African American

Subjective

Chief Complaint: right ankle pain for 3 days

History of Presenting Illness: JD is a 46-year-old African American female who presents with bilateral ankle pain. The pain is asymmetrical and worse on her right ankles. This pain started the last weekend when she was playing soccer and heard a ‘pop’ in her ankles. She can bear weight over her ankles but is concerned about her right ankle. Walking up the stairs or running exacerbates the pain but rest and Advil relieved the pain. The pain is burning and worse with movement. She rated it 6/10 on the pain scale. There is no associated bruising or swelling over her ankles. This is the first time she is experiencing such pain in her ankles. She has not sued any medications for her pain. The pain is limited to the ankles and does not radiate to the leg or foot

Current Medications: no current medications

Allergies: she has no food or drug allergies that are known

PMH: she is not diabetic, hypertensive, asthmatic, or epileptic. She denies a history of rheumatoid arthritis. She has no past major illnesses or surgeries. Her last flu shot was last month and her last tetanus toxoid dose was about 10 years ago

Social History: she works as a school accountant. She enjoys playing soccer during her free time.  She does not drink alcohol or smoke tobacco. She is married with two children: a boy (nine years) and a girl (6 years) – all alive and well. She uses her seat belt every time and exercises daily – at least for 20 minutes

Family History: her father 78 has heart failure, and her mother, 74, has diabetes mellitus. Her maternal and paternal grandparents died of ‘old age.’ Her children are alive and well. No history of rheumatoid arthritis, asthma, or hypertension in her family.

GENERAL: no fever or weight loss

HEENT: no headache, blurry vision, hearing impairment, nasal congestion,  sore throat, or swallowing difficulty

SKIN: no rashes or itchiness

CARDIOVASCULAR: no fatigue, chest tightness, leg swelling, or heart racing

RESPIRATORY: no difficulty in breathing, chest pain, or cough

GASTROINTESTINAL: no burping, diarrhea, constipation, nausea, vomiting, or abdominal pain

GENITOURINARY: no dysuria, vulval itchiness, or discharge; last menstrual period was June, 28^th 2022. She is para 2+0 and not pregnant currently. She is on IUCD for contraception

NEUROLOGICAL: no numbness, weakness, paralysis, tingling, dizziness, or incontinence

MUSCULOSKELETAL: no muscle pain or swelling, no back pain or stiffness, no joint stiffness

HEMATOLOGIC: no easy bruising, history of recurrent infections,

LYMPHATICS: no edema

PSYCHIATRIC: no sleep disturbances, anxiety, or depression

ENDOCRINOLOGIC: no polyuria, polydipsia, heat intolerance, or fatigue

Objective

GENERAL:  Alert and oriented in all spheres, good nutritional status, not in any respirational distress; VS: 118/78 mmHg, HR 74/minute, RR 18/minute, SpO2 97% in room air, height 165cm, weight 74kgs, BMI 27.2

HEAD: no bruises or scars, normal hair distribution

EENT: PERRL, extraocular muscular movements intact, no leukocoria, nor ear discharge, TM pink and intact bilaterally, no nasal septal deviation, discharge, no tonsillar enlargement or pharyngeal redness, no neck masses or stiffness

CHEST: chest moving with respiration bilaterally, no tracheal deviation, all filed resonant, chest clear to auscultation bilaterally

CARDIOVASCULAR: peripheral pulses are all present and have no delays, no collapsing pulses, precordium normoactive, no halves, lifts, or thrills, S1 & S2 heard, no murmurs, apex beat at the 5^th ICS MCL

ABDOMEN: no marks, scars, or masses visible, the abdomen of normal fullness, inverted umbilicus, no ascites, no organomegaly, no tenderness, tympanic in all fields, bowel sounds heard, no inguinal lymphadenopathy

EXTREMITIES: normal gait, the talus is well aligned with the tibia in both legs and feet; tandem walk test normal, no bruises or swelling, power 5/5 in all limbs and joints, the tone is normal in all limbs, reflexes normal in the ankle, knee, and elbow bilaterally, no crepitation in major joints, tenderness over the left and right ankle joint, tenderness limited to 4cm above and below medial and lateral malleoli. Range of portions not limited to ankle, knee, metatarsal, hip, elbow, and metacarpal joints. Left ankles are not erythematous and not swollen. The right ankle is slightly swollen but not erythematous. Ankles are warm to the touch, pedal pulses are present in both limbs, and popliteal pulses are also present. Drawer tests, talar tilt tests, and Kleiger tests were not done due to tenderness.

Diagnostic results: no diagnostic tests done so far. However, I would order random blood sugar to rule out diabetes owing to her weight and positive family history. I would also order for rheumatoid factor assay to rule out rheumatoid arthritis owing to her gender and age. By applying the Ottawa ankle rules, I would not need additional foot or leg radiography because the pain does not extend to the 6cm distal of lateral and medial malleoli tips, no navicular bone tenderness and the patient could bear weight (Ball et al., 2022). The patient exhibited normal cerebellar function and the local sensation is normal (Leblond et al., 2020). Therefore, the possibility of a fracture can be ruled out.

Differential Diagnoses

Sprain of unspecified ligament of right ankle, initial encounter. S93. 401A: Ankle sprain is the most likely differential diagnosis in this patient due to a history of risk factors in a contact sport (soccer) (Zhao et al., 2021). Pain and swelling are the important positives. The pop sound could be a result of a slip of ligaments in the ankle during playing soccer.

Achilles tendinitis, right leg- M76. 61: This type of Achilles tendon injury is likely in this patient due to pain. However, the pain is moderate as opposed to typical pain in Achilles tendonitis which is usually acute and severe in cases of tendon rupture.

Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement. M05. 771: her age and gender are key risk factors that may suggest this diagnosis in her. However, RF tests that would be ordered would determine further tests for this diagnosis (Dains et al., 2019). Joint swelling and pain could also suggest RA in this patient due to the joint inflammation

Idiopathic gout, right ankle, and foot- M10. 071: due to pain and swelling in her right ankle this diagnosis is likely (Glynn & Drake, 2022). However, her gender makes this diagnosis less likely. The moderate severity also makes gout less likely as well as lack of erythema over the joint. The joint (ankle) involved is also typical of acute gouty arthritis.

Primary osteoarthritis, right ankle, and foot · M19.071: Osteoarthritis is also likely in this patient. Pain in the right ankle and left ankle makes OA a possible differential (Rao et al., 2012). Her OA would be secondary and posttraumatic owing to the timelines of her presentation. However, the acute presentation of the symptoms and younger age (,65 years) make this differential less likely.

 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2022). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier – Health Sciences Division.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). Mosby.

Glynn, M., & Drake, W. M. (Eds.). (2022). Hutchison’s clinical methods: An integrated approach to clinical practice (25th ed.). Elsevier Health Sciences.

Leblond, R. F., Brown, D. D., & Suneja, M. (2020). Degowin’s Diagnostic Examination, 11th Edition (11th ed.). McGraw-Hill Education/Medical.

Rao, S., Riskowski, J. L., & Hannan, M. T. (2012). Musculoskeletal conditions of the foot and ankle: assessments and treatment options. Best Practice & Research. Clinical Rheumatology, 26(3), 345–368. https://doi.org/10.1016/j.berh.2012.05.009

Zhao, Y., Zhao, Y.-Z., & Yu, S.-D. (2021). Clinical efficacy of sticking-needle acupuncture plus tendon-regulating manipulation in the treatment of acute ankle sprain. Journal of Acupuncture and Tuina Science, 19(6), 469–474. https://doi.org/10.1007/s11726-021-1275-3