Peer responses week 8 nurs 6512
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Responseweek8.docxResponse to
Sharda Vekariya
Week 8, Initial Post
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Episodic/Focused SOAP Note for Knee Pain
Focused SOAP Note for KV with right knee pain
Patient Information:
Initials: KV, Age: 19, Sex: F, Race: Asian
Subjective.
CC “My knee hurts”.
HPI: KV is a 19-year-old Asian female presented to this clinic today with a gradual onset of right knee pain, which began five days ago. She described the pain as “Sharp” and is rated 5 out of 10 on a severity pain scale of 0-10 x 5 days. Reported constant localized pain. The pain is located on the medial upper side of the knee without any associated symptoms. She reports feeling anxious and fearful. She reports falling last week during soccer practice and applying ice to her knee with some relief. The patient tried Advil 200 mg with minimal relief with pain but noted more swelling and pain today. Reports need to use crutches for ambulation, pain increases with placing weight on right leg.
Current Medications:
· Advil 200 mg Q6 hr prn pain, last dose 8 am on 07/20/21
· Tylenol 325 mg 2 tabs prn headache, last dose 1 month ago
· Zoloft 50 mg PO BID Anxiety last dose 07/20/21
· Arnica 200, 5 globules for irregular menstruation 07/18/21
Allergies:
Penicillin: rash
PMHx:
· Fall
· Headache
· Irregular menstruation
Immunization:
· Childhood immunization UpToDate
· HPV vaccine 2020
· Tdap vaccine 2020
· Covid-19 vaccine x2 dose 2021
PSHx:
· Denies surgical history
Soc Hx: Works part-time at a tutoring center and completing bachelor’s studies in science. Her hobbies include playing soccer, traveling, and listening to music. She has access to healthcare and medications through health insurance from work. She lives with a friend in a rental apartment in a moderately safe area. She denies using a cellphone and always uses a safety belt while driving. She reports having good social support from family and friends. She identified as a straight woman and had one previous healthy relationship with a boyfriend of 2 years. She reported her relationship ended due to different interests in life. She is an atheist by religion.
Lifestyle:
· Denies substance use or drugs
· Denies use of tobacco or e-cigarette
Family Hx:
· Father: Diabetes, Hypertension, Hyperlipidemia, alive, age 51 yrs.
· Mother: Arthritis back, Depression, Gout, alive, age 54 yrs.
· Maternal grandfather: hypertension, died of heart attack @ age 42 yrs.
· Maternal grandmother: Arthritis, alive, age 76 yrs.
· Paternal grandfather: Hypertension, smoker, alive age 82 yrs.
· Paternal grandmother: Hypertension, diabetes, died of hypotension during dialysis, age 72 yrs.
· Brother: Obese, age 26 yrs.
Review of System:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Head: Reports occasional headaches. Denies visual loss, blurred vision, or double vision. Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching, extra growth, or dryness.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. Denies syncope episode.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. Denies abdominal pain or blood in the stool.
GENITOURINARY: Denies burning on urination. Denies ever being pregnant. Last menstrual period, 05/20/21.
NEUROLOGICAL: Reports occasional headaches. Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Reports having right knee pain with swelling, worse on movement. Reports neck stiffness at times while being on the phone for a long time.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Reports having an anxiety disorder. Denies history of depression.
ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Denies excessive thirst or hunger.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
Objective
VS: BP 120/60, HR 70, RR 17, T. 98.9. O2 100%, Wt. 115 lbs. Ht. 5’3”
General: AO x3, answers questions appropriately. Appears slightly anxious. Sitting up with stable posture. Noted limping upon ambulation and use of crutches.
Cardiovascular: No visible chest pulsation. Negative for orthopnea. AP diameter wnl. PMI to midclavicular 5th intercostal space. No edema to lower extremities except right upper medial knee swelling.
Pulmonary: No visible abnormal findings. Lungs are clear to auscultation and percussion bilaterally.
Gastrointestinal: Flat abdomen without visible abnormal findings. No palpable masses. Denies any abdominal pain. No loss of bowel or bladder control
Musculoskeletal:
Hips: Asymmetric. Expected ROM for flexion, extension, abduction, and adduction. Muscle strength 5/5.
Knees:
Right knee: appearance asymmetric, warm to touch, soft, +2 edema, +ve bruising. No visible or palpable mass or joint deformity. No tingling or paresis. Pain intensity increases upon placing weight on the right leg. Patella slightly displaced laterally. Slight restricted ROM for flexion and extension.
Left knee: symmetric, No visible discoloration, mass, or edema. Flexion, extension, abduction, and adduction within expected ROM.
Lower legs: No abnormal finding below the knee area. Symmetric bilaterally.
Ankles: symmetric, no visible abnormal findings. Flexion, extension, abduction, and adduction within expected ROM.
Diagnostic results:
· Thorough history
· Right knee 3-view X-ray
· Laboratory: CBC
Assessment
Differential Diagnoses:
1.) Right Anterior crucial ligament injury
2.) Right knee septic bursitis
3.) Patellar dislocation
Primary diagnosis:
1.) Right Anterior Crucial ligament injury
From a thorough history interview, this patient reported a fall one week ago during her dance practice. Anterior crucial ligament injuries are significantly rising among females after puberty (Reiko et al., 2021). Side-to-side asymmetry of lower extremities can influence the risk of injury-related with drop jump leading to anterior crucial ligament among females more than males (Gu et al., 2021). The female dancers have a lower ACL injury risk compared to female soccer players (Lim et al., 2021). Faulty body mechanism during dynamic movement causes excessive valgus force at the knee and increases the risk of ACL injury (Nessler et al., 2017).
Septic bursitis is generally reported with diffuse swelling a few hours after injury. The patient may report a restricted range of motion on flexion. Diffuse tenderness, warmth, erythema, and swelling to extensor surfaces, and low-grade fever is a hallmark of septic bursitis (Tuff & Chrobak, 2016). This patient does not have a fever or diffuse swelling around the knee but has localized edema.
Lateral patellar dislocation is the most common injury among young patients. Age, skeletal immaturity, sex, mechanism of injury, and excessive weight, and anatomical risk factors are identified for patellar dislocation (Parikh et al., 2018). This patient is not overweight and does not have any anatomical deformities.
Plan:
· Nonpharmacological treatment
· Pharmacological treatment
References
Gu, C.-Y., Li, X.-R., Lai, C.-T., Gao, J.-J., Wang, I.-L., & Wang, L.-I. (2021). Sex disparity in Bilateral Asymmetry of Impact Forces during Height-Adjusted Drop Jumps. International Journal of Environmental Research and Public Health, 18(11). https://doi-org.ezp.waldenulibrary.org/10.3390/ijerph18115953
Lim, B.-O., An, K.-O., Cho, E.-O., Lim, S.-T., & Cho, J.-H. (2021). Differences in anterior cruciate ligament injury risk factors between female dancers and female soccer players during single- and double-leg landing. Science et Sports, 36(1), 53–59. https://doi-org.ezp.waldenulibrary.org/10.1016/j.scispo.2020.02.005
Nessler. T., Denney, L., & Sampley J. (2017). ACL injury prevention: What does research tell us? Current Review Musculoskeletal Medicine. 2017 Sep;10(3):281-288. doi: 10.1007/s12178-017-9416-5.
Parikh, S., Lykissas, M., & Gkiatas, I. (2018). Predicting risk of recurrent patellar dislocation. Current Review Musculoskeletal Medicine. 2018 Jun;11(2):253-260. doi: 10.1007/s12178-018-9480-5.
Reiko Otsuki, Daniel Benoit, Norikazu Hirose, & Toru Fukubayashi. (2021). Effects of an Injury Prevention Program on Anterior Cruciate Ligament Injury Risk Factors in Adolescent Females at Different Stages of Maturation. Journal of Sports Science & Medicine, 20(2), 365–372. https://doi-org.ezp.waldenulibrary.org/10.52082/jssm.2021.365
Tuff, T., & Chrobak, K. (2016). Septic olecranon and prepatellar bursitis in hockey players: a report of three cases. Journal of the Canadian Chiropractic Association, 60(4), 305–310.
Response to
Review of Case Study #1, Back Pain
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History and physical examination of the musculoskeletal system are crucial as every other system, as it provides stability and mobility for physical activity. The provider needs to utilize a systematic approach to evaluate the musculoskeletal system because it is the body’s line of defense against external forces that solely depend on the structure and functions of the bones, tendons, ligaments, and joints. The purpose of this assignment is to develop an episodic/focused SOAP note based on a case study, A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg.
Episodic/Focused SOAP Note Template
Patient Information:
Initials: AJ Age: 42 years, Sex: Male
S.
CC: The patient presented in the clinic with “pain in the lower back” for the past month.
HPI: Mr. AJ is a 42-year-old Caucasian male who presented to the clinic with pain in the lower back for the past month. Patient reported sharp pain that sometimes radiates to his left leg. No injury or falls predisposing to the current symptom. His pain is six on a scale of 0-10 scale. The pain aggravated with activity and was relieved by rest at times. However, he reported that his daily activities are disturbed due to pain. AJ stated he took Ibuprofen 600 mg this morning with no relief.
Current Medications:
Lipitor 10 mg PO daily for high cholesterol
Amlodipine 2.5 mg PO daily for high blood pressure
Ibuprofen 600 mg PO every 6 hours as needed for pain.
Allergies: No known drug allergies
No food allergies, no latex allergies, no seasonal allergies.
PMH:
Medical: Hypertension, Hyperlipidemia
Surgical: No surgeries in the past
Hospitalization: No reported hospitalization in the past.
Immunization: Vaccinations are up to date Last flu shot 2020. Tdap 2015.
Social Hx: Mr. AJ is married. He lives in a single-story house with his wife and two children. He is sexually active with his wife as his only partner. He is heterosexual. He denies smoking or the use of recreational drugs. AJ drinks occasionally, 1-2 drinks weekly. He is a full-time IT employee. He is active and walks approximately two to three miles per pay. He does bicycle during his days off. The current symptom affected his exercise tolerance. He does not follow a special diet; however, he eats a healthy diet, 2-3 meals per day. He drinks 2-3 cups of coffee every day. Mr. AJ’s primary language is English. He is spiritually active and a member of a local Methodist church. He does not have a living will, but his wife has an active role in making decisions related to their life. He reports following safety rules while driving and avoiding texting as much as possible while driving.
Family History:
Father: Alive, he has diabetes and COPD.
Mother: Alive. She has hypertension and arthritis
Paternal grandfather: Deceased at the age of 75, with a heart attack
Paternal grandmother: Deceased at the age of 70, of unknown cause.
Maternal grandfather: Deceased, age 65 with complications from COPD.
Maternal grandmother: Deceased, age 75, with unknown cause.
Siblings: One brother, 38years has hypertension. One sister,33years is healthy and has no other health history.
Children: two daughters are healthy with no significant medical history.
ROS:
GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT:
Head: Denies headache, head trauma or injury.
Eyes: Denies visual loss, blurred vision, or double vision.
Ears, Nose, Throat Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure, heart murmur, or irregularities in rhythms, or chest discomfort. Denies palpitations or edema. The last EKG was two years ago at the physical.
RESPIRATORY: Denies shortness of breath, cough, or sputum. Does not recall the last chest x-ray or TB test.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. Denies weight loss, difficulty swallowing, or change in appetite.
GENITOURINARY: Denies burning, frequency, or difficult urination. Denies erectile dysfunction or penile discharges.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies change in bowel or bladder control. Denies numbness or tingling of the extremities.
MUSCULOSKELETAL: Complaints of back pain, sometimes radiating to the left leg for the past month. AJ reports difficulty walking at times due to pain. Denies arthritis, gout, or musculoskeletal injury.
HEMATOLOGIC: Denies anemia, bleeding, or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. Denies excessive thirst, or urination.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
General: Mr. AJ is a well-developed, well-nourished male, who is alert, oriented, and cooperative. The patient is a good historian. He is sitting upright at the exam table. Appears in slight discomfort while sitting upright without back support due to pain.
Vital signs: BP: 142/85, HR: 90, R: 16, Temp- 98.6 F. weight: 174 LB, Height: 5’7”. BMI: 28.
Skin: Intact, warm, and dry. No lesions, cyanosis, jaundice, pallor or rashes noted.
HEENT: Head normocephalic, atraumatic. Pupils are equal and reactive to light. Wearing glasses. No hemorrhage or exudate is seen on the fundal exam. The external auditory canal is patent, with no swelling or discharges. The nasal cavity is patent. No deviated nasal septum or polyps were noted. The buccal mucosa is intact without lesions. Dentition is good. No bleeding, thrush, or gum swelling was noted.
Neck: Full range of motion. No carotid bruit. No thyromegaly. No masses palpated or tracheal deviation noted.
Cardiovascular: Heart rate and rhythm are regular. S1 S2 heard on auscultation. No murmur gallops, or pericardial friction rubs. No bruits of the abdominal aorta. Pulses are 3+ symmetrical bilaterally. No peripheral edema was noted.
Respiratory: breath sounds clear on all lung fields. Chest expansion even and unlabored. No use of accessory muscles.
Abdomen: soft, round, and non-tender. No masses or organomegaly. Bowel sounds are present in all quadrants. There is no guarding or rebound noted.
Musculoskeletal: Full ROM of all extremities except slight limitation of movement in left leg due to pain. Mobility limitation of back noted with bending and stretching. No swelling, joint effusion, or cyanosis was noted. No spinal deformity noted. No kyphosis, lordosis, or scoliosis noted.
Neurological: alert and oriented X 3. Cranial nerves grossly intact. Mood and affect appropriate. Upper extremities 5/5. Left lower extremities 4/5, right lower extremities 5/5. Sensation is intact to pinprick.
Lab/Imaging: Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. Most patients with acute back pain, with or without radiculopathy, have substantial improvements in pain and function in the first 4 weeks. Routine imaging is unlikely during this time (Chou et al., 2011). Imaging is not required to confirm the diagnosis and is only requested if pain persists for more than 12 weeks or the patient develops progressive neurological deficits (Jensen et al., 2019). Plaine radiographs may not be enough to rule out the cause of back pain. Some of the causes of back pain, such as Lumbar disk herniation or spinal stenosis are radiographically detected only with advanced imaging such as CT or MRI (Stynes et al., 2016).
Primary Diagnosis: Sciatica
Sciatica is a clinical diagnosis based on symptoms of radiating pain in one leg with or without associated neurological deficits on examination Pain most commonly radiating posteriorly at the leg and below the knee. Numbness and paresthesia of the leg may or may not be involved. Most patients improve over time with conservative treatment including exercise, manual therapy, and pain management(Stynes et al., 2016). Sciatica is a type of lumbar radiculopathy, where the pain originates from the lumbar and/or sacral nerve roots. Provider must refer the patient urgently if there is urinary retention or decreased anal sphincter tone, which suggest cauda equina syndrome (Stynes et al., 2016).
Differential Diagnoses:
1.Ankylosing Spondylosis: A chronic inflammatory condition of the spine may affect the cervical, thoracic, and lumbar spine along with the sacroiliac joints. It develops predominantly in men between 20 and 40 years of age and begins insidiously with inflammatory low back and buttock pain, also involving hips and shoulders. Buttock pain can fluctuate from one side to the other (Ball et al., 2019). Ankylosing spondylitis has a genetic predisposition associated with human leukocyte antigen (Ball et al., 2019). This condition is ruled out due to the inflammatory nature of the disease and the presented symptom.
2. Lumbar Stenosis: lumbar stenosis is narrowing of the spinal canal, lateral recesses, or interbody vertebrae which causes bone or soft tissue to compress nerve roots. The classic presentation is lower back pain, radiating to the leg, thighs, or buttocks. The characteristics of pain are aching, burning, cramping, and sharp and typically bilateral, worsens with walking, prolonged standing, and lumbar extension. And the classic characteristic is an improvement with flexion (Andaloro, 2019).
3. Lumbosacral Radiculopathy (Herniated Lumbar Disk): It is generally caused by degenerative changes of the disk. Most commonly occurring at the L4, L5, and S1 nerve roots. The greatest incidence occurs between 31 and 50 years of age. Common symptoms include low back pain with radiation to the buttocks and posterior thigh or down the leg in the distribution of the dermatome of the nerve root. Pain relief is often achieved by lying down. Spasm and tenderness over the paraspinal musculature may be present. A potential difficulty with heel walking (L4 and L5) or toe walking (S1). Numbness, tingling, or weakness in the involved extremity (Ball et al., 2019).
4. Piriformis syndrome: Piriformis syndrome occurs due to sciatic nerve entrapment at the level of the ischial tuberosity. While there are multiple factors that may contribute to piriformis syndrome, the clinical presentation is consistent. Patients often report pain in the gluteal region that is characterized as shooting, burning, or aching down the back of the leg. In addition, numbness in the buttocks and tingling sensations along the distribution of the sciatic nerve is not uncommon. Causes of piriformis syndrome include trauma to the hip or buttock area, piriformis muscle hypertrophy (often seen in athletes during periods of increased weightlifting requirements or pre-season conditioning), sitting for prolonged periods (taxi drivers, office workers, bicycle riders). Treatment includes short-term rest (not more than 48 hours), use of muscle relaxants, NSAIDs, and physical therapy (which entails stretching the piriformis muscle, range of motion exercises, and deep-tissue massages). In some patients, injection of steroids around the piriformis muscle may help decrease the inflammation and pain (Hicks et al., 2021).
5. Osteoporosis: Osteoporosis is the loss of mineralized bone mass that results in a compression fracture of the vertebral body, mainly occur in the thoracic area. It is more common in Caucasians, women, and older people. It is a silent disease until fractures occur, which causes important secondary health problems and even death (Sözen et al., 2017). There typically are no symptoms in the early stages of bone loss. But once the bones have been weakened by osteoporosis, there will be signs and symptoms, which include, back pain caused by a fractured or collapsed vertebra, loss of height over time, a stooped posture (Sözen et al., 2017).
Plan:
1.Nonpharmacological interventions:
· Exercise
· physical therapy,
· application of superficial heat/ cold in the lower back area (Agency for Healthcare Research and Quality, 2016)
1. Nonpharmacological interventions:
· NSAIDs: Ibuprofen 600 mg PO every 6 hours as needed for pain.
· Muscle relaxant: Valium 5 mg PO every 8 hours.
· Systemic corticosteroids: Prednisone 10 mg daily for one week
1. Follow up with PCP if the symptoms do not get better.
References
Agency for Healthcare Research and Quality. (2016). Noninvasive Treatments for Low Back Pain: Current State of the Evidence. https://effectivehealthcare.ahrq.gov/products/back-pain-treatment/clinician
Andaloro, A. (2019). Lumbar spinal stenosis. Journal of the American Academy of Physician Assistants, 32(8). https://doi.org/https://journals.lww.com/jaapa/Citation/2019/08000/Lumbar_spinal_stenosis.9.aspx
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's Guide to Physical Examination: An Interprofessional Approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chou, R., Qaseem, A., & Owens, D. K. (2011). Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine. https://doi.org/https://www.acpjournals.org/doi/10.7326/0003-4819-154-3-201102010-00008
Hicks, B. L., Lam, J. C., & Varacallo., M. (2021). Piriformis Syndrome. NCBI. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK448172/
Jensen, R. K., Kongsted, A., Kjaer,, P., & Koes, B. (2019). Diagnosis and treatment of sciatica. BMJ. Retrieved July 20, 2021, from https://doi.org/https://www.bmj.com/content/367/bmj.l6273.full
Sözen, T., Özışık, L., & Başaran, N. Ç. (2017). An overview and management of osteoporosis. European Journal of Hematology, 4(1). https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5335887/#!po=2.63158
Stynes, S., Konstantinou, K., & Dunn, K. M. (2016). Classification of patients with low back-related leg pain: a systematic review. BMJ Musculoskeletal Disorder. https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4877814/
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