NR 511 Week 7 Faculty Tip Sheet - Musculoskeletal

• Past medical history: o Osteoporosis • Family history: o Cancer • Social history: o Smokes • ROS: o General: Normal o Integumentary/breast: Normal o HEENT/Neck: Normal o Cardiovascular: Normal o Respiratory: Normal o Gastrointestinal: Normal o Genitourinary: Normal o Musculoskeletal: Back pain that radiates down right leg from low back to right posterior calf. o Allergic/immunologic: Normal o Neurologic: Normal o Psychiatric: Normal Coaching students if they have questions about the history-taking: History-taking should focus on describing the back pain. For this client: • The pain is worsening (8/10) with radiation down the right leg from low back to right posterior calf EHR documentation objective data: Physical exam: • Vital sign: o Elevated BP (136/80) • Neurological: o Alert and oriented o 4/5 resisted right ankle dorsiflexion and plantar flexion o 5/5 resisted left ankle dorsiflexion and plantar flexion o Diminished light-touch perception on the medial aspect of the right lower extremity to the medial malleolus o Right straight leg raise: Pain radiating down the leg to below the knee when hip flexed to 45 degrees o Crossed straight leg raise: Positive symptoms in right leg • Musculoskeltal: o Spinal extension worsens back pain ©2020. Chamberlain University, LLC. All rights reserved. 2 Must not miss diagnoses: • Herniated disk: since it fits most of the key findings for this case, this diagnosis is the lead diagnosis • Vertebral fracture: given the pain caused by this condition, and its risk factors, which include cancer, this is a must not miss diagnosis • Spinal stenois or cauda equina syndrome: this diagnosis may have poor outcomes for patients and its treatment is surgical. Therefore, it is a must not miss diagnosis Diagnostic tests: Remind students to determine what tests are needed to “rule-in” or “rule-out” each diagnosis. The student should select the following. The client’s results are also included to help guide the student’s diagnosis and management plan: • MRI: is the preferred imaging test because it provides excellent visualization of the disks. • Radiographs and CT scans: can be used to evaluate for infection, fracture, and other structural bony pathologies. • According to the American College of Radiology Appropriateness Criteria, initial imaging with x-ray, CT without contrast, or MRI without contrast is usually appropriate for patients with low back pain with or without radiculopathy and one or more of the following: low-velocity trauma, osteoporosis, elderly individual or chronic steroid use. o Since this patient already has x-rays done at urgent care and her symptoms have progressed, MRI was required for this case. o This patient’s MRI findings: ▪ The 5-lumbar type are presumed. The vertebral alignment is anatomic. The vertebral body heights are maintained. The is diffuse increased T1 marrow signal throughout the visualized spine compatible fatty marrow replacement in the setting of osteopenia. No other bone marrow signal abnormality is seen. ▪ The conus terminates at T12-L-1. The conus and visualized cord are within normal limits in caliber and signal ▪ There is mild degenerative disk disease manifested by loss