TITLE OF CASE
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Multiple Emergency Department Encounters for Acute
Musculoskeletal Presentation with an Existing Mental Health
Diagnosis |
SUMMARY
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Reconceptualising acute Musculoskeletal (MSK) injuries with both stress-
and tissue- based factors is required to consider prior influences of
mental health disorders on acute persistent musculoskeletal pain
presentations involving an extremity. This report highlights repeated
emergency presentations for acute persistent musculoskeletal pain
involving an extremity for an individual in their 20s living with mental
health diagnoses ranging across Depression, Mood Disorders and an eating
disorder. This person also had mental health related inpatient
admissions that were not captured under the retrospective record review
for a large district hospital emergency department using the
Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)
classification system. This case report attempts to demonstrate that
improving the understanding of pre-existing vulnerabilities and mental
health diagnoses may assist with informing healthcare design to develop
specialised care pathways for acute injury presentations with triage
settings. |
BACKGROUND
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Acute MSK pain represents a
common cause for seeking emergent health care
(1),(2).
While the majority of acutely injured people should expect to recover
spontaneously, 50% will transition from acute to chronic pain and
disability (3,
4).
Data from robust clinical trials (5) and
prevalence studies have failed to enable us to adequately identify
individuals at risk of delayed recovery from MSK injury, and
interventions targeting known risk factors have yielded, at best, only
modest effects (6,
7). Furthermore, the most recent output
from the global burden of disease in 2019 suggest MSK conditions are a
leading cause of civilian years lived with disability. Alarmingly, this
has not changed since 1990, suggesting research has had little effect on
reducing the burdens of acute and chronic MSK conditions. Perhaps
critical to this long-standing problem is that research has not
generated new mechanistic knowledge into why some people recover and
others do not following their acute MSK presentation.
(8).
Perhaps reconceptualising the acute MSK injury (be it a slip-and-fall,
motor vehicle collision, fracture, muscle strain affecting the spine or
extremities) as both a stress- and tissue-based injury is required to
integrate and consider how pre-existing diatheses such as mental health
disorders (9) influence the process of
recovery. By identifying patients who may be vulnerable to costly
negative chronic outcomes, appropriate early screening tools and
preventative treatments can be offered to improve clinical outcomes and
avoid harmful secondary effects, such as opioid dependency, stigma, poor
return to work outcomes, withdrawal from valued life roles, long-term
reliance on ineffective and costly management options and repeat
emergency department (ED) encounters.
For example, people living with mental health conditions tend to
experience adverse physical health outcomes and significantly more
medical conditions as compared to others without a history of mental
health disorders. This is not to suggest the presence of a mental health
disorder(s) predisposes a person to a life of chronic pain following
adulthood injury requiring emergent care. While it is acknowledged that
the Emergency Department environment presents a challenge, if not a
trigger, to both busy, time-strapped, clinicians, and the patients
themselves, knowledge of pre-existing diatheses could inform and
streamline new clinical pathways for acute MSK injury on a
patient-by-patient basis.
The case of a Caucasian woman in her twenties seeking repeated ED
management over a 7 year period is used to highlight the challenges for
both the patient and the healthcare providers in, and beyond, the
ED.
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CASE
PRESENTATION
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The repeated voluntary ED presentations (38 visits over 7 years, from
January 2015 – February 2021) were observed to be for persistent
musculoskeletal pain, involving an extremity and upper limb pain.
Pre-existing diagnoses of Mood Disorder, Depression, and an Eating
Disorder (Anorexia Nervosa) were recorded at each ED presentation of
persistent MSK pain involving an extremity, and while considered, did
not feature in the clinical work-up.
The retrospective record review was approved by the Northern Sydney
Local Health District Human Research Ethics Committee, ethics approval
number – 2021/STE02301: SSA.
Design
Retrospective interrogation of electronic medical records obtained from
January 2015 until July 2021 capturing relevant data for acute
presentations of MSK pain intersecting with mental health admissions
over the preceding 12-month periods at a district hospital Emergency
Department.
Setting
Emergency department triage facility for a large urban district hospital
serving a catchment of over 1.5 million people.
Subject
A case report of an individual in their twenties, with multiple ED
presentations (38 visits) over a 7 year period, classified by the
treating ED physician/ clinicians using the SNOMED CT system at each
presentation. The SNOMED CT is defined as a standardised, multilingual
vocabulary of clinical terminology containing more than 300,000 medical
concepts used by health care providers within the electronic exchange of
clinical health information (10,
11) . The SNOMED CT is made up of the
numerical codes, known as concepts, used to identifying clinical
information. The number of concepts used are largely if not completely
dependent on the clinical setting and patient census. In this case, the
number of concepts available in a busy urban ED with level 1 trauma
status is in the thousands.
The concepts are divided into different groups such as body structure,
clinical findings, geography, location and biological products
represented by different concepts based on the complexity of the
presenting condition. The terminology classifies presentations under
findings, disorders, diagnoses and similar with individual numbers.
SNOMED CT classifies “findings” as observations which may be objective
or subjective information from a primary source, including human
observation whereas the term “disorder” refers to as an abnormal
clinical state and are classified under the hierarchy of disease
(10). SNOMED CT however also tends to be
subjective and have the same description while referring to different
concepts due to the ambiguity dependant on the triage
(12).
The ED admission data captured the date, the patient’s reason for the
visit to ED, MSK diagnosis provided at triage, and the pre-existing MH
diagnosis. Under SNOMED CT, findings refer to observations that exist at
the time of recording, while disorder suggests an abnormal and
underlying psycho-physical pathological process that remains a
vulnerability even post completion of treatment
(11).
As summarised in Table 1, the repeated MSK/ acute pain related
presentations observed over the 2-year period were for persistent
musculoskeletal pain involving an
extremity(11).
There were multiple mental health related admissions separate to the
acute MSK pain presentation at ED over this period recorded initially
for an unspecified mood (affective) disorder, progressing to Dysthymia/
Mood Disorder, followed by a separate admission for Post-traumatic
stress disorder (PTSD), a further mental health admission for
Dissociative convulsions, and the last captured admission was for
Anorexia Nervosa (classified under Eating Disorder/s).
Information regarding social circumstances, such as living independently
or in supported accommodation, employment or education status, social
supports both informal and formal including community mental health
services, General Practitioner and any non-governmental organisations
involvement was not available.
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