Pain Case Study (Case Study Sample)

Pain Case Study Student’s Name Institutional Affiliation Instructor Course Date Pain Case Study Medical Diagnosis: Pain Acute musculoskeletal strain or muscle strain occurs when a muscle is torn or overstretched. The patient medical diagnosis is a sharp shooting pain on the lower back. The pain increased and spread to her right buttocks.   Pathophysiology:  An acute musculoskeletal strain occurs due to indirect distress or stress due to excessive application of force. Often joint muscles contract leading to the tension. Some of the most predisposing factors that may lead to muscle strain include warm-up and inadequate rehabilitation. An acute strain may be due to indirect or direct trauma. In the case of direct trauma, a contusion is produced at the contact point. Indirect trauma is whereby there is no contact, but myofibers are dislocated (Derry et al., 2015). Injuries also cause an acute musculoskeletal strain. Severe strains are characterized by complete tear and can be due to fatigue, reduced flexibility, and lack of warm-ups before physical activity. An acute strain can occur when one is running, jumping, lifting a heavy object, standing or working in an awkward position, or while one slips. The situation is often worse during the cold season since muscles stiffen when temperatures are low.    Risk Factors: Acute musculoskeletal strains vary on the angle of movement and direction of applied force. Strains and contusions make the most significant number of strain complications. Often they take place in contact areas where significant compression occurs on a muscle. The main muscles at risk of an acute musculoskeletal strain include;  1 Muscles with a high amount of type II fibers; they involve muscles most involved in movements such as rotator cuff, deltoid, erector spinae, hip abductors, hip flexors, quadriceps, gastrocnemius, and hamstring.  2 Muscles that contract eccentrically; Eccentric and concentric contractions occur during practical sessions that lead to tensions and later myofiber overload tear.  3 Two joint muscles; Movement at a joint may trigger muscle-tension leading to overstretch (Derry et al., 2015) Most acute strains are mainly due to repetitive movements. Movements that can increase one’s risk include poor posture, playing sports such as baseball, golf, tennis, and rowing. Acute musculoskeletal strains risks mainly include one’s hobbies and work where a lot of physical activity is required, and muscles are put in high use. For example, failure to condition the body muscles before a vigorous exercise may increase the likelihood of acute musculoskeletal strain. Failure to warm up before strenuous activity is often risky, and the chances of getting a muscle strain are high (Derry et al., 2015). Body muscles are more likely to experience a strain when they are fatigued. Other risk factors include excessive or overuse of the muscles.   Prevention: There are many ways of preventing acute musculoskeletal strain. They include: 1 Proper hydration  2 Stretching muscles daily 3 In the case of an injury, one should wait to heal before engaging in any activity 4 Slight physical exercise/warming up 5 Eating potassium-rich diet 6 It is also vital to engage an expert if one has a frequent acute musculoskeletal strain that lasts for long on daily management practices Clinical Manifestations: Evident clinical symptoms of acute musculoskeletal strain include muscle weakness, pain at the joints or specific muscle, pain while resting, and redness at the point of injury. Other clinical manifestation includes pain while relaxing and discomfort while moving/walking.  Assessment and Diagnostic Findings: The assessment of acute musculoskeletal strain should focus on the mechanism of the strain, the timing of the injury, pain intensity, and pain location (Derry et al., 2015). Other assessments should focus on observing the point of injury, the temperature of edges, movement range, visible deformity, and bone tenderness.   Medical Management: Pierik et al. (2016) argued that medical management entails pain relief strategies such as relaxing, using ice over the strained part, compressing the area to keep from swelling, and elevating the injured part. Raising the injured area helps in reducing the chances of swelling.  · Pharmacological Acetaminophen (Tylenol) or Anti-inflammatory medications are used to minimize swelling or pain. Ibuprofen is effective in reducing the healing period. Paracetamol is preferred for minor strains.  · Surgical Surgery is most preferred if the patient has a torn muscle, although it comes with numerous risks, including reduced healing, pain, blood clots, and excessive bleeding (Pierik et al. 2016).  Gerontologic Considerations: The primary gerontology consideration in the treatment and management of acute musculoskeletal strain is the fragility of the body due to old age. Due to weakened muscles and bones, it is critical to apply management strategies of treatment that cannot put the patient’s life at risk (Pierik et al., 2016). Old age is thus a crucial factor while choosing a management strategy or treatment.  Bedside Shift Report on Pain History: This is Mrs. Brown. She is a 45-year-old female, is an office manager for a busy law firm and a single mother of two children. While cleaning her shower stall she experienced a sharp pain in her lower back. Over the next few hours her lower back became increasingly more painful. By the time she picked up the children from their sporting event and drove to the nearest ER, she had sharp shooting pain into her right buttocks. Her spinal x-rays were not significant and she was diagnosed with acute musculoskeletal strain and given anti-inflammatories, hydrocodone 5mg/acetaminophen 500 mg by mouth every 6 hours as needed for pain, and instructed to rest her back for the next 24 hours. Neurological * Oriented to person, place, time, and situation * Sleepy but easily roused * Complains of discomfort when repositioning. Cardiovascular * Heart rate = 90 * No murmurs, clicks or rubs noted * Blood pressure 118/60 Respiratory * Respiratory rate = 20 * Lung sounds clear to auscultation GI/GU * Abdomen is soft, non-tender, and non-distended * Urine is clear yellow * Last bowel movement yesterday, large, brown, and formed Skin * Intact Musculoskeletal * Able to reposition herself as needed Psychosocial * Concerned she is missing work * Does not know what to do with her children Assessment -Data collected from Bedside Shift Report. Subjective -A sharp pain on the lower back and buttocks and sudd...