Assessment of the Musculoskeletal System Essay

Assessment of the Musculoskeletal System Essay

Assessment of the Musculoskeletal System Essay

Patient Information: K T. Age: 15 years, Gender: male

S.

CC (chief complaint) “The Knee is painful.”

HPI: The fifteen-year-old patient came to the facility indicating that he had knee pain. The onset of the knee pain was last week. The patient indicates that he experiences clicking sounds on both knees. He also says to be experiencing a catching sensation under the patella.

Location: bilateral knees

Onset: over one week ago, when he played basketball

Character: The pain is intermittent and dull

Associated signs and symptoms: catching sensation under the patella

Timing: Just over a week

Exacerbating/ relieving factors: pain increases with walking. The patient feels better when resting and when the knees are in contact with packed ice.

Severity: Pain goes to 10 when walks for long but reduces to 6 when taking pain medication

Current Medications: currently uses ibuprofen

Allergies: no known allergies

PMHx: Had rheumatic fever during formative years and had sprained knee close to half a year ago.

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Soc Hx: does not use alcohol and does not smoke

Fam Hx: Both parents are still alive, with the father being obese. His grandmother is living with diabetes.

ROS:

GENERAL:   denies fatigue, weakness, and weight loss but reports pain in the knee.

HEENT: No double vision, blurred vision, or loss of vision. No hearing loss, congestion, stuffy nose, or pain in the throat.

SKIN:  no itches or rashes.

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

RESPIRATORY:  No cough or breath shortness.

MUSCULOSKELETAL:  Pain in both knees.

PSYCHIATRIC:  No anxiety or depression.

ALLERGIES: No hives or asthma history.

O.

Physical exam:

HEENT: No headache. No loss of vision, eye discharge, and no hearing loss.

Cardiac: No irregular heart rate observed

Extremities: no sign of tenderness or edema. However, the knees are a bit misaligned with the thigh bone.

Skin: The skin is warm and intact, with no rashes observed.

Diagnostic results: Magnetic Resonance Imaging, complete blood count, Bilateral Knee X-ray, and Computerized Tomography.

There is a need to do an assessment of any abnormalities while performing musculoskeletal exams. An alignment with the edge between the tibia and femur for the lower extremities under fifteen degrees has to be performed (Shih et al., 2020). For a possible fracture, the range of motion has to be assessed. Various tests are also important, including checking for meniscus tear through the McMurray test, anterior cruciate ligament using the Lachman test, and checking the stability of the knee through the use of the Varus-valgus stress test.

A.

Osteogenic Sarcoma: This is one of the most likely conditions in this patient’s case. One of the major symptoms is intermittent pain, and is a condition common among individuals between the ages of ten and twenty-five years (Arora & Shaikh, 2021).

Patellar dislocation: This is a condition that is indicated when the knee patella shifts from the usual position. In most cases, the patient complains of pain in the patella, which was the case for this patient (Parikh et al., 2018).

Medial Meniscus– medial Meniscus is usually characterized by catching of the knee movement, clicking, and complications with flexing and knee pain. Some of these symptoms were observed in the patient (Benard et al., 2020).

Patellar fracture: patellar fracture occurs when there is a cracking or breaking of the kneecap leading to pain in the knee. This pain also presents with knee bruising and swelling (Parikh et al., 2018).

Patellar Chondromalacia: This occurs when the cartilage in the knee cap has been injured. Discomfort and pain then follow. This pain can be enhanced by involvement in physical activity (Özel, 2020).

References

Arora, R. D., & Shaikh, H. (2021). Osteogenic sarcoma. In StatPearls [Internet]. StatPearls Publishing.

Bernard, C. D., Kennedy, N. I., Tagliero, A. J., Camp, C. L., Saris, D. B., Levy, B. A., … & Krych, A. J. (2020). Medial meniscus posterior root tear treatment: a matched cohort comparison of nonoperative management, partial meniscectomy, and repair. The American journal of sports medicine, 48(1), 128-132. https://doi.org/10.1177%2F0363546519888212

Özel, D. (2020). The relationship between early-onset chondromalacia and the position of the patella. Acta Radiologica, 61(3), 370-375. https://doi.org/10.1177%2F0284185119861901

Parikh, S. N., Lykissas, M. G., & Gkiatas, I. (2018). Predicting risk of recurrent patellar dislocation. Current Reviews in Musculoskeletal Medicine, 11(2), 253-260.  https://doi.org/10.1007/s12178-018-9480-5

Shih, Y. C., Chau, M. M., Arendt, E. A., & Novacheck, T. F. (2020). Measuring lower extremity rotational alignment: a review of methods and case studies of clinical applications. JBJS, 102(4), 343-356. Doi: 10.2106/JBJS.18.01115

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Assessment of the Musculoskeletal System
You Will
• Evaluate abnormal musculoskeletal findings
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system

This week is to have a discussion to participate in.
To prepare:

• Your Discussion post should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template (See below)
Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

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.

Case 3: Knee Pain

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:

• 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.

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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 i.e. 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: Denies weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.
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. No polyuria or polydipsia.
ALLERGIES: Denies 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.
P.
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 7th edition formatting.