Discussion Week 8 _Assessing Musculoskeletal Pain

Instructions:

· Respond to your colleague who was assigned a different case study than yours.

· Analyze the possible conditions from your colleagues' differential diagnoses.

· Determine which of the conditions you would reject and why.

· Identify the most likely condition, and justify your reasoning.

**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 2

Episodic/Focused SOAP Note Template

Patient Information:

I. T. , 15 y/o, M, AA

S.

CC: “I been having a dull like achy pain in both my knees and sometimes I feel a catching feeling in either one knee or sometimes both”.

HPI: I. T. 15 y/o, AA, male patient who presents to clinic today with complaints of bilateral knee pain for the past 7 days that is described as a dull pain which is a 6/10 pain. The pain is at times accompanied by a “clicking” noise and catching sensation under his patella. It is exacerbated by physical activity such as running and is aggravated more with basketball practice. He reports ibuprofen and rest alleviates the pain.

Current Medications: Ibuprofen 500mg as needed for knee pain. Daily vitamins. Adderall 25mg daily in the morning.

Allergies: Penicillin- hives.

PMHx: UTD on vaccines. History of patellar dislocation, Tonsillectomy 2019. Soc Hx: I.T. non-sexually active teen who lives with mother, parents divorced, has visitation with his father on weekends. Denies tobacco use, illicit drugs, or alcohol use. Reports wearing seat belt at all times when in car. He participates in extra curriculum activities basketball and tutoring. He enjoys time with his friends and playing video games. Sleeps 8-9 hours at night.

Fam Hx: Both parents still living. Mother-39 y/o, hx of depression, Father-37 y/o, arthritis, hypertension, Sister-5 y/o no significant history.

ROS:

GENERAL:  Denies weight loss, or gain, no change in appetite, denies fever, chills, or fatigue.

HEENT:  No blurred vision, no loss of hearing, or ringing in ears, denies runny nose, congestion and sore throat, no swelling or tenderness of lymph nodes.

SKIN:  Denies rash or itching and lesions.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, or cough.

GASTROINTESTINAL:  Denies nausea, vomiting or diarrhea. No abdominal pain.

GENITOURINARY:  Denies any difficulty in urinating or burning.

NEUROLOGICAL:  Denies headache, dizziness, numbness or tingling in the extremities.

MUSCULOSKELETAL:  Reports pain to bilateral knees, pain with knee extension and tenderness.

HEMATOLOGIC:  Denies anemia, bleeding, or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety or mental illness.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Reports penicillin-hives.

O.

Physical exam:

Vital signs: BP:118/65, P:80, RR: 19, O2stat: 100% RA, T: 98.6, Weight: 145lbs, H: 5’9 BMI: 21.3

GENERAL: Well groomed, appropriate, sitting on exam table answering questions, making eye contact.

HEENT:  Normocephalic, atraumatic, no hearing difficulties, good oral hygiene, no swelling, or tenderness to lymph nodes.

SKIN:  Intact, appropriate for ethnicity, no rashes, lesions, or dryness.

CARDIOVASCULAR: RRR without murmur, no edema, palpable pulses bilaterally.

RESPIRATORY:  Lung sounds clear in all lobes, no cough, no SOB. Chest expansion symmetric and equal.

GASTROINTESTINAL: Abdomen non distended, symmetrical, no tenderness on palpation, bowel sounds present in all 4 quads. No n/v/d.

GENITOURINARY:  Genitalia not examined.

NEUROLOGICAL:  AAOX4, no tremors or focal deficits, moves all extremities.

MUSCULOSKELETAL: + knee pain bilaterally, tenderness and 6/10 pain on extension, mild edema. Apley’s (-), McMurray’s (+), Lachman’s test (-). Patellar grind (+).

PSYCHIATRIC:  Calm, appropriate and cooperative.

ALLERGIES:  Reports penicillin-hives.

Diagnostic results:

X-ray to evaluate for fracture, dislocation or Osgood-Schlatter’s disease. X-ray is a simple test to create a two-dimensional picture of the bone that forms the joint. This procedure can help disclose any issues that involve the bones, surface of joints and joint spaces (Starkey & Brown, 2015).

MRI- this procedure utilizes a solid magnet connected to a computer to produce a photo of the knee joint in highly contrasting black and white. It is especially helpful in diagnosing wounds to the cartilage, tendons, ligament’s tendons, and menisci, and also places swelling (Arthritis Foundation, 2018).

Erythrocyte Sedimentation Rate (Sed-rate) blood test used to determine if inflammation is present. The higher the sed-rate, the more accurate the measure of inflammation.

A .

Differential Diagnoses.

1. Osgood-Schlatter’s Disease- it is common cause of knee pain in males ages 11-15 years old. The pain is usually exacerbated by physical exercises like running, bouncing, and climbing stairs (Vaishya, Azizi, Agarwal, & Vijay, 2016).

2. Patellofemoral syndrome- usually is an onset of diffuse pain starting from the front knee, most regularly in young, active competitors, particularly sprinters.

3. Patellar dislocation- shifting of the knee patella from its normal positioning. The condition is characterized by pain in the patella (Ball et al., 2015).

4. Bursitis- is the inflammation of the bursa. This condition is characterized by edema, warmth and tenderness on the knee, and knee pain (Dains, Baumann, & Scheibel, 2016).

5. Patellar Chondromalacia- condition in which the cartilage in the kneecap is worn by age or injury. The condition is characterized by the discomfort of the inner knee, pain that aggravate from physical activity or extended rest and swelling in some cases (Medscape, 2016).

References

Arthritis Foundation, (2018). X-ray, MRIs, and Other Imaging Tests for Knee Diagnosis. Retrieved from https://www.arthritis.org/about-arthritis/where-it-hurts/knee-pain/diagnosis/knee-mri.php.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Starkey, C., & Brown, S. D. (2015). Examination of Orthopedic & Athletic Injuries. Retrieved from https://books.google.com/books?hl+en&lr=&id=yMnXBgAAQBAJ&oi=fnd&pg=PR1&dq+types

Vaishya, R., Azizi, A. T., Agarwal, A. K., & Vijay, V. (2016). Apophysitis of the Tibial Tuberosity