Assignment: Assessing Neurological Symptoms

Episodic/Focused SOAP Note Template

 

Patient Information:

Age:15 years Sex: Male

S.

CC: “dull pain in both knees with clicking in both knees and a catching sensation under the patella.” The additional history that is required for the patient will be acquired through asking questions like the onset of pain, the duration and the related symptoms ad the previous treatment of the pain.

HPI: the patient is a 15 years old male who comes to see the doctor stating that he has been experiencing knee pain and he states that he has been experiencing clicking sounds from the two knees.

Location: knees

Onset: two months ago

Character: dull pain

Associated signs and symptoms: a catching sensation under the kneecaps.

Timing: after playing volleyball.

Exacerbating/ relieving factors: ice park.

Severity: 7/10 pain scale

Current Medications: ibuprofen.

Allergies: no known environment, food, and medication allergies.

PMHx: immunization is up to date. No past illness or surgery.

Soc Hx: the patient is a student who is a volleyball player. He lives with his parents, he denies any use of alcohol, smoking, or illicit drug use.

Fam Hx: the patient lives with his parents and two siblings a brother and a sister. There is no musculoskeletal condition in his family.

ROS:

GENERAL:  the patient is a healthy 15 years old male who has maintained a healthy body. He is oriented and alert and he has no complaints of any other joint.

HEENT:  He denies headache. Eyes: he denies loss of vision. Ears, Nose, Throat: has no hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:  normal.

CARDIOVASCULAR:  has a regular heart rate and no murmur.

RESPIRATORY:  The patient denies a cough and shortness of breath.

GASTROINTESTINAL:  denies any vomiting or nausea.

GENITOURINARY:  The patient denies any changes in the urinary pattern.

NEUROLOGICAL:  no dizziness and denies any changes in memory or thinking pattern.

MUSCULOSKELETAL:  The patient states that he has been having difficulty moving his knees after football.

HEMATOLOGIC:  Denies excessive bruising and bleeding disorders.

LYMPHATICS:  Denies enlarged nodes.

PSYCHIATRIC:  Denies sleeping difficulties or suicidal ideations.

ENDOCRINOLOGIC:  no endocrine symptoms.

ALLERGIES: no food, environmental, and drugs allergies.

O.

Physical exam:

Vital Signs: BP: 117/74, P: 92, T: 98.6, RR: 17, Wt.130lbs, Ht. 5’8, BMI: 19.1

General: The patient is a well-nourished, well-developed teenage male and he appears to be in no apparent distress.

HEENT: No lesions or masses, PERRLA, direct and consensual pupil response, no masses, lesions, tenderness or drainage, no nasal flaring, oropharynx clear, and mucosa moist.

Lungs: regular respiration without cough.

Heart: regular rate rhythm.

Abdomen: soft and non-tender without rash.

Genital/Rectal: no masses noted and adequate tone.

Skin: the patient’s skin is moist and intact.

Musculoskeletal: no focal joint inflammation.

Neurological: awake, alert, and oriented.

Diagnostic results:

Bilateral knee x-ray, computerized tomography (CT) scan, CBC, and MRI.

A .

Differential Diagnoses

Primary: Patellar tendinitis (M76.50). It is an injury to the tendon that joins the kneecap or the patella to the shinbone. The patellar tendon works with the muscles at the thigh front to stretch the knee to help one run, kick and jump (Brennan et al., 2017). This condition is most common in athletes where the activity involves frequent jumping. The first symptom of this disease is pain, normally between the kneecap and where the tendon joins to the shinbone. At first one might only feel pain in the knee as one begins physical activity. After some times the pain increases and it starts to hinder playing sports. In this case, the patient plays volleyball that includes a lot of jumping and running and this adds strain to the knee joints.

Osgood Schlatter’s disease (ICD-10 M92.5). This is a condition that brings about pain as well as swelling below the knee joint, where the patellar tendon joins with the shinbone top. There might be also inflammation of the patellar tendon that extends over the kneecap (Cealrey, 2017). The painful symptoms are mostly caused by jumping, running, and other sports. In some of the cases, both knees have the symptoms however one knee might be worse than the other knee.

Chondromalacia patellae (icd-10 M22.40). This is the softening and breakdown of the tissue on the kneecap underside. Pain results when the thigh bone and the knee rub together. Dull, aching pain or a feeling of grinding when the knee is flexed might take place. Some of the symptoms of this condition involve the dull, aching pain behind the kneecap, below the kneecap, and on the sides of the kneecap. This condition might be possible to the patient because of the knee pain due to pain with activity. However, this condition is common in female patients or an individual with a history of knee trauma.

Medial meniscus tear (icd-10 S83.242A). The condition is related to knee pain, clicking, difficulty flexing, and catching of the knee movement and this is just like the case of our patient (Jacksonville Orthopaedic Institute, 2021). This condition is a possibility since it can take place after a twisting injury and here the patient participates in sports that involve twisting movements.

Patellar fracture (icd-10 S82.0). the condition is where the kneecap suffers cracking or breakage and brings about pain in the knee together with swelling and bruising around the knee. Even though the patient in this case study does not have all these symptoms it is a probability.

P.   

References

Brennan, D., Allen, T. W., & Sanders, K. (2017). What is the efficacy of eccentric exercises for the treatment of patellar tendonitis? Evidence-Based Practice, 20(1), E6-E7. https://doi.org/10.1097/01.ebp.0000541617.80642.d7

Cealrey, D. (2017). Osteochondropathies of the knee: Osteochondritis Dissecans and Osgood-Schlatter disease. Orthopedic Surgery Clerkship, 547-551. https://doi.org/10.1007/978-3-319-52567-9_115

Jacksonville Orthopaedic Institute. (2021). Medial meniscus tear. https://www.joionline.net/trending/content/medial-meniscus-tear