Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. 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.
This purpose of this assignment is to review case study #3 knee pain, and use the information to evaluate, form possible diagnoses, and practice documenting in soap format. Documenting in SOAP note format allows a practitioner to assess and document that the patient was treated with a holistic approach (Ball, Dains, Flynn, Solomon, & Stewart, 2019).
Case 3: Knee PainA 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?
Patient Information:ANW 15 1/19/04 M Caucasian
(CC): “My knees hurt, sometimes I hear a clicking sound, and they get stuck.”
History of Present Illness (HPI): Alexander (Alex) is a 15 year old Caucasian male who has come to the clinic complaining of pain in his knees. He states “sometimes it is just one knee that clicks and sometime it is both,” Alex states that his “knees get stuck or catch under the knee cap”. He rates the pain as 3/10 most days but after games the pain can be 6/10. He describes the pain as “dull and achy,” like I have done too much stuff. He states the pain started “a few weeks ago” and it was once in a while but now they hurt almost every day. He said his coach wants him to get his knees checked out before the next game.
Medications: Motrin 200mg po Nightly.
Past Medical History (PMH): None
Past Surgical History (PSH): None Sexual/Reproductive History: Heterosexual. Identifies as male. Denies sexually active.
Personal/Social: Alexander is a sophomore He plays on the basketball, baseball, soccer, football, track and wrestling team. He also loves to swim but states they do not have a team at the school. Alex states although he loves sports he wants to become a “sports doctor” and be a sports coach in his part time. Alex is proud of his 4.2 GPA and plans to graduate 1 year early and start college. He lives with his mother, adoptive father, maternal grandmother, and older sister. Alex says he has a half-brother that is 5 that leaves in Tennessee with his biological father. He states his biological father had a baby boy that died at birth a few years ago. He reports seeing his biological father a few times in the last few years. He states he has a girlfriend is named Heather, is also a sophomore and that she is a cheerleader and also plays soccer. He reports that he and Heather are not sexual active but if they become active they will use condoms. Alex is excited to get his license soon. He reports he wears his sit belt in the car and wears all protective sport gear. Denies tobacco use, drinking, illicit drug use. Reports he tried Marijuana x1 and a beer in 2018 at a party.
Immunization History: All immunization up to date per mother. Received flu vaccine 10/2018. Verified through Florida Immunization Registry.
Family History: Mother: Hx Breast Cancer. Seasonal Allergies. Anxiety. Maternal Grandmother: Asthma Paternal Grandfather: Died in 2009 liver Cirrhosis from etoh abuse.Father: MI age 30 from cocaine abuse. Bipolar disorder. Maternal Grandmother: None Paternal Grandfather: Substance AbuseSister: 19 Asperger’s, Anxiety, Depression. Half-Brother- 5 Cerebral Palsy Half Brother-Deceased Still Born
ROS:General: Denies fatigue, weakness, fever, chills, sweat, loss of appetite, and weight loss. HEENT: Denies any wounds, lumps, or pain. Denies vision issues. Denies hearing issues. Reports a nose bleed once last year after being hit during a soccer game. Reports no issues eating, swallowing, or pain in throat. Reports he saw the dentist last week.Neurological: Denies headaches, pain, and dizziness or head injuries. Denies changes in memory. Denies numbness and tingling.Skin: Denies any wounds, rashes or moles. Reports, “I have a birth mark on my right butt check”.Cardiovascular: Denies chest pain, palpitations, and racing. No hx noted.Peripheral Vascular: No hx noted.Respiratory: Denies SOB, cough, and pain.Gastrointestinal: Denies abdominal pain, nausea, vomiting, constipation or diarrhea. Reports not troubles eating. Reports he eats “lots of pasta for energy”.Genitourinary: Denies issues including nocturia, dribbling, incontinence, discharge, or pain upon urination. Musculoskeletal: Reports knee pain bilaterally dull and achy 3/10 presently. Denies issues, running, jumping, kicking, or bending. Reports clicking sounds at times when knee is flexed and extended. Hematologic: Denies bleeding or bruising. Reports nose bled last year after being hit in a soccer game. No other hx notedLymphatics: Denies swelling and tenderness. No Hx noted.Endocrine: Denies heat or cold intolerance, excessive thirst or urination, or tremors. No hx noted.Psychiatric: Denies depression, thought of self- harm. Reports anxiety when taking Chemistry tests.Allergies: Denies.Physical Exam: BP 120/70 adult cuff/right arm/sitting, P 72 regular, RR 18 unlabored. O2 98%, T 98.6 temporal. Weight 185. Height 5 feet 11 inches. BMI 25General: Aox4, looks stated age, pleasant, well groomed, and cooperative. Makes eye contact when speaking and answering questions. No s/s of distress.HEENT: Head symmetrical No visual deformities noted. PER/EOMI. Responds to questions with no requests to repeat. Breaths through nares no s/s of congestion, or allergies. Teeth are intact, bright white, straight, and no odor from mouth present.Neurological: AOX4, No s/s of neurological deficits. Adequate recall.Neck: No visual lesions, no enlargement, no JVD. Skin/Lymph: Intact. No wounds, lesions, scars or moles noted. Tan in complex. No signs of edema or cyanosis. No nodes observed upon palpation. Chest/Pulmonary: Chest is symmetrical. CTA AP&L. Respiration even and unlabored noted at 19. No noted SOB, RR noted at 18, SPO2 98%. No use of accessory muscles noted. Heart/Vascular: S1 and S2 noted. RRR. No murmurs, rubs, or gallops noted. Less than 3 capillary refill. All Pulses 3+. HR slightly elevated along with BP indicative of pain.Abdomen: Deferred No issues noted. Genital/Rectal: Deferred no issues noted.Musculoskeletal: Ambulates on own, full weight bearing. Mild swelling, tenderness, warmth noted in bilateral knees. Pain with palpation over the tibial tuberosity. Flinches upon flexion and extension of both knee.Diagnostic Results/Manipulation Test: Negative Lachman test. Negative Homan’s sign. Negative McMurray test. Differential Diagnoses 1. Patellofemoral Pain Syndrome 2. Meniscus tear 3. Osgood Schlatter Disease 4. Osteogenic Sarcoma 5.Stress fracture
The most probable diagnosis for Alex is Petellofamoral pain syndrome. This syndrome is pain that is caused by overuse of the knee caps (American Academy of Orthopedic Surgeons, 2015). It is prevalent in those who play sports, especially those that involve jumping and running (Mayo Clinic, 2018). This syndrome causes pain around the knee cap, stiffness, and may also cause the popping and clicking sound that Alex describes and that is present upon evaluation (American Academy of Orthopedic Surgeons, 2015). This condition is sometimes called runner or jumper’s knee (American Academy of Orthopedic Surgeons, 2015). Alex plays multiple sports that have high impact on the knees. It is common in women and in adolescents (American Academy of Orthopedic Surgeons, 2015). Alex has the signs and symptoms of this condition, including pain upon examination. This condition would explain the pain that Alex’s is reporting in both versus an injury that would be more likely to shoe in just one knee. Another possible diagnosis for Alex is bilateral torn meniscuses. A meniscus tear is when there a tear takes place to the cartilage that is located behind the knee cap (American Academy of Orthopedic Surgeons, 2014). It is one of the most common knee injuries, especially in those that play sports (American Academy of Orthopedic Surgeons, 2014). The signs and symptoms of this condition are swelling, stiffness, clicking or popping sound, not being able to extend the knee fully, and a feeling that your knee is going to “give out” (American Academy of Orthopedic Surgeons, 2014). Alex is very active in many different sports and shows all signs and symptoms of this condition except for negative McMurray sign. McMurray test is a manipulative test is that performed to detect a tear in the meniscus (Ball et al, 2019). A palpable or audible click with this maneuver means that there is tear present in either the lateral or medial meniscus (Ball et al, 2019). It is very unlikely that Alex would have a torn meniscus in both knees at the same time Osgood Schlatter Diease is yet another possible diagnosis for Alex. This condition is a swelling and irritation of the growth plate in the legs near the shine bone (Kids Health Nemours, 2019).This condition usually takes place in children who are still growing and that have active lifestyles (Kids Health Nemours, 2019). This condition is common in those who play sports that involving running and jumping (American Academy of Orthopedic Surgeons, 2015). Alex is the correct age for the condition and is very active in the sports that cause this condition. This condition would explain the pain Alex is experiencing but not necessarily the clicking or popping sound. Although Osteogenic Sarcoma is a less likely diagnosis for Alex it may still be a possible diagnosis. Osteogenic Sarcoma is a type of cancer that forms at the ends of bones as they grow (Johns Hopkins Medicine, n.d). It affects those younger in age still growing (Johns Hopkins Medicine, n.d). Alex does fit the age range, with the most common age being 15 (Johns Hopkins Medicine, n.d). This condition would explain the pain being reported, however this condition is a very rare (Johns Hopkins Medicine, n.d). An Xray , MRI and CT will be able to establish if a tumor is present (Johns Hopkins Medicine, n.d). It would be very unlikely that this condition will present in both knees at the same time. Additionally this condition would not explain the clicking and pooping sounds present in the knees. A stress fracture or tiny break in a one is another possible diagnosis for Alex due to his increased sports activity (American Academy of Orthopedic Surgeons 2007). Stress fractures are a very common injury in those that play sports (Dains, Baumann, & Scheibel, 2019). Although the stress fracture would cause the pain is experiencing it would not explain the clicking in the knees. Additionally it is unlikely unless Alex has a previous condition such as osteoporosis that both knees would experience a fracture at the same time. An Xray of the knees will be able to establish if a fracture exists. Treatment Plan: Diagnostics Bilateral patella XRAY Bilateral MRI of patella CT Scan
MedicationTreatment RICE treatment. Mobic 7.5mg po daily. Knee stretching exercise.
Education Patient and parent on diagnosis. RICE therapy. Medications usage and side effects. Educate on stretching. Provide stretching pamphlet. Referral and follow-up.
Referral/Consultation Pediatric orthopedist Physical therapyFollow Up Planning 1 month
American Academy of Orthopedic Surgeons.(2014). Meniscus Tears. https://orthoinfo.aaos.org/en/diseases–conditions/meniscus-tears/American Academy of Orthopedic Surgeons. (2015). Osgood-Schlatter Disease (Knee Pain). https://orthoinfo.aaos.org/en/diseases–conditions/osgood-schlatter-disease-knee-pain/American Academy of Orthopedic Surgeons. (2015). Patellofemoral Pain Syndrome. https://orthoinfo.aaos.org/en/diseases–conditions/patellofemoral-pain-syndrome/American Academy of Orthopedic Surgeons. (2007). Stress Fractures. https://orthoinfo.aaos.org/en/diseases–conditions/stress-fractures/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.Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.Johns Hopkins Medicine. (n.d). Osteogenic Sarcoma. https://www.hopkinsmedicine.org/kimmel_cancer_center/centers/pediatric_oncology/becoming_our_patient/cancer_types/osteogenic_sarcoma.htmlKids Health Nemours. (2019). Osgood Schlatter Disease. https://kidshealth.org/en/parents/osgood.htmlMayo Clinic. (2018). Patellofemoral pain syndrome. https://www.mayoclinic.org/diseases-conditions/patellofemoral-pain-syndrome/symptoms-causes/syc-20350792
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