NURS 6512 Assessing musculoskeletal pain week 8 assessment Sample solution

NURS 6512 Assessing musculoskeletal pain week 8 assessment Sample solution

Case Study:
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

With regard to the case study you were assigned:

Review this week's Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.		 

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

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

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

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

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6^th edition formatting.

NURS 6512 Assessing musculoskeletal pain week 8 assessment Sample solution

 

Assessing Musculoskeletal Pain

Patient Information

 

Initials: L.F. Age: 15 years Sex: Male Race: Caucasian

Subjective:

CC: “I have noticed that both of my knees have been sore recently.”

 

HPI: L.F is a Caucasian male who is 15 years old and reports feeling dull pain in both of his knees. w He noted that occasionally either one or both of his knees would click, and he also reports a catching feeling beneath the kneecap. It’s been roughly two months since the pain started, but there are no other indications linked with it. Rest or ibuprofen may ease the persistent pain, which is exacerbated by physical activity like walking. He indicated that the discomfort was only a three out of ten while he was at rest, but that it increased to a seven out of ten when he was conducting vigorous activity.

Current Medication: Ibuprofen 200mg PO PRN

 

Allergies: NKA

PMHx: Denies medical or surgical history.

 

Social Hx: He lives with his siblings and parents in a rented apartment. Currently, he is enrolled at one of the local high schools. He has no record of ever smoking cigarettes, drinking alcohol, or using illegal drugs in the past. He also has no history of using any other substances. Soccer, skating, and playing computer games are some of the things he enjoys doing in his spare time.

Family history: Father: age 44, history of diabetes, Mother: age 40, history of cystic fibrosis, Brother: age 8, asthma, Sister: age 5, healthy.

Immunization Hx: All immunizations are up to date.

ROS

 

GENERAL: denies fever, chills, recent weight changes, or fatigue.

MUSCULOSKELETAL: Reports bilateral knee joint pain. Denies muscle pain, back pain, joint swelling or stiffness.

Objective:

Vital signs: BP-108/65, HR-77, RR-16, SPO2-99% on room air, Temp-98.4, Ht- 4’6”, Wt- 99 lbs., BMI- 23.4

GENERAL: Pleasant patient, in no acute distress. Appears well developed and well-nourished. Alert and oriented x3. He is cooperative and has a clear and coherent speech.

Musculoskeletal: bilateral knee joints appear mildly swollen, without deformities. Warmth and tenderness of the knee joints noted on palpation. Full ROM normal in all joints, no stiffness or crepitation. Positive Lachman test. McMurray and Homan sign test negative.

Diagnostic tests:

Lateral knee x-ray

Assessment

Differential diagnosis

Osgood Schlatter disease– This condition affects the growth plate, which causes it to swell and become inflamed. Pain at the front of the knee, which is worsened by movement and improved by rest and activity reduction, is a hallmark symptom of this condition.  Knee pain in youngsters aged 8 to 15 is often caused by this condition (Ladenhauf et al., 2020). As a high school soccer player, the patient is within the age range at risk for developing Osgood Schlatter disease.

Tibial tubercle avulsion fracture– This is a knee injury that often affects teenage males at the transitional period of physeal closure, which occurs just before development is considered to be complete, and it takes place when they are participating in sports. It may be recognized by the swollen and sensitive appearance of the front tibia, as well as by the presence of palpable bone fractures (Franz et al., 2020). When the patient’s knees were palpated, however, there were no bone fractures that could be felt anywhere in either knee.

Patellofemoral pain syndromes– This is a disorder that causes discomfort at the front of the knee joint, and it is caused by a confluence of variables that are both internal and external. Knee pain that is characteristic of the condition may be described as aching, dull, and even sometimes shooting or sharp (Gaitonde et al., 2019).

Patellar tendonitis– This occurs when the patella tendon has been overworked and has sustained an injury as a result. Irritation and soreness of the patella tendon, as well as pain experienced while bending or straightening the affected leg, are the hallmarks of this condition (MacDonald et al., 2020).

Hoffa’s syndrome– This is a disease in which there is a compression of the knee fat pad between the patella and the femoral condyle. This causes stress to the fat pad, which results in pain in the front of the knee joint and mild to severe irritation in the knee joint that is impacted by the trauma (Genin et al., 2017).

 

References

Franz, P., Luderowski, E., & Tuca, M. (2020). Tibial tubercle avulsion fractures in children. Current Opinion in Pediatrics, 32(1), 86-92. https://doi.org/10.1097/mop.0000000000000870

Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral pain syndrome. American family physician, 99(2), 88-94. https://pubmed.ncbi.nlm.nih.gov/30633480/

Genin, J., Faour, M., Ramkumar, P., Yakubek, G., Khlopas, A., Chughtai, M., King, D., & Mont, M. (2017). Infrapatellar fat pad impingement: A systematic review. The Journal of Knee Surgery, 30(07), 639-646. https://doi.org/10.1055/s-0037-1604447

Ladenhauf, H. N., Seitlinger, G., & Green, D. W. (2020). Osgood–Schlatter disease: A 2020 update of a common knee condition in children. Current Opinion in Pediatrics, 32(1), 107-112. https://doi.org/10.1097/mop.0000000000000842

MacDonald, K., Palacios-Derflingher, L., Kenny, S., Emery, C., & Meeuwisse, W. H. (2020). Jumper’s knee: a prospective evaluation of risk factors in volleyball players using a novel measure of injury. Clinical Journal of Sport Medicine, 30(5), 489-494.