Assessment of the Musculoskeletal System: A Case Study of Knee Pain in a 15-Year-Old Male, Assignments of Nursing

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Week 8: Assessment of the Musculoskeletal System Discussion: Assessing Musculoskeletal Pain INITIAL POST Episodic/Focused SOAP Note Patient Information: JB, 15years old, Caucasian, Male Subjective Data Chief Complaint: The patient presents to the clinic with the complaints of dull pain in both knees for past five days and sometimes one or both knees click with the catching sensation under the patella. History of Present Illness : JB is a 15-year-old Caucasian male who presents to the clinic for bilateral anterior knee pain described as dull, accompanied by “clicking” and a “catching” sensation under the patella. He reports the pain started 5 days ago while playing soccer and “gets worse” while running. He states mild relief with rest, ice and use of ibuprofen. Patient states pain level of 7/10 when engaging in activity Current Medications : Ibuprofen 400mg every eight hours as needed. Allergies: No known allergy to medication, food, and environment. Past Medical History:

Social History : JB is a sophomore in local public school where he is in honors classes and plays soccer and baseball. Lives with married parents and two younger siblings, sister age 8, and brother age 6. Denies alcohol, tobacco and illicit drug use. Always wears a seat belt and he has working smoke detectors in the house. He says living environment is safe and, supportive family member. Family History : No history of illnesses with possible genetic predisposition, no contagious or chronic illnesses. No history provided about the family member. Review of System: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Head: no head injury. Eyes: No visual loss, blurred vision, double vision or yellow sclera. 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: No burning on urination, urgency or frequency

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: bilateral knee pain 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. Objective Data: Vital Sign: BP 90/75; T 98.6; P 115; R 22; o2 96% RA; Weight 120lbs; Height 5’ 1’’ Physical exam : GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Head: no head injury. Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or open lesions.

CARDIOVASCULAR: Heart rate and rhythm regular with S1 and S2, no S3 and S4 heard, no murmur. RESPIRATORY: Respiration unlabored, no cough or sputum. GASTROINTESTINAL: Abdomen Soft, non-tender on palpation, no nausea, vomiting, or abdominal pain. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Bilateral knee pain with “clicking and catching”, swelling present in both knees. Diagnostic Test: History collection and physical examination helps to diagnose the patient problem (Ball, Dains, Flynn, Solomon & Stewart, 2015). MRI scan considered most accurate and noninvasive method of diagnosis (Epocrates, 2018). X-ray of knees (Anterior, Posterior, and Lateral view), and arthroscopy; although usually performed to repair or resect the torn meniscus, arthroscopy can be used to confirm diagnosis (Epocrates, 2018). Assessment : Differential Diagnosis:

1. Patellofemoral pain syndrome: It is defined as knee pain resulting from mechanical and biochemical changes to the patellofemoral joint which is one of the most common disorders of the knee, accounting for 25% of knee injuries seen in a sports medicine clinic

(Epocrates, 2018b). The causes of patellofemoral problems are multifactorial, including (Epocrates, 2018b). abnormal patellofemoral joint mechanics, lower kinetic chain alterations, and overuse. There is no initial test, but Knee X-ray, MRI or CT scan will help to confirm diagnosis (Epocrates, 2018b).

2. Meniscus tears. The meniscus is a rubbery C-shaped disc that cushions knee and acts as a shock-absorber. It also helps spread weight evenly so the bones don’t rub together. Tears to the meniscus are often caused by sudden twisting or other things while playing sports. In young people, tears usually happen during a traumatic event, but as we age the meniscus can tear more easily (Hill, 2014). It can result from playing sport or normal activities of daily living. The athletic population is at greatest risk, especially those who participate in twisting sports (commonly football, soccer, and basketball) (Epocrates, 2018).
3. Osteochondritis Dissecans: A joint condition in which some parts of the joint cartilage and bone lose their blood supply due to an unknown etiology, and may detach from the joint surface. Adolescents are commonly affected and it may be present with knee pain and swelling. Catching of the knee can occur, especially during or after sporting activity (Epocrates, 2018).
4. Posterior cruciate ligament sprain: Patient is often able to continue activity but they note that the knee does not feel right. Instability may be subtler, with knee effusion typically small and less noticeable. In addition, the posterior drawer test is positive (Epocrates, 2018). MRI scan reveals disrupted posterior cruciate ligament (Epocrates, 2018).
5. Patellofemoral osteoarthritis: Deep retro-patellar pain and tenderness and swelling on undersurface of patella which can be confirmed Radiography.

As an advanced practice nurse, it is important to gather sufficient history and complete physical examination before making any differential diagnosis and diagnosis. Knees pain could be due to various reason such as arthritis, ligament tear, sprain, or it also could be due to other systemic problem. Check for the range of motion (ROM) if it is limited because of pain, weakness or any deformity (Dains, Baumann & Scheibel, 2016). Based on the patient’s history and present illness, diagnostic result, the possible diagnosis would be patellofemoral pain syndrome. To confirm the diagnosis, more information and diagnostic test is required. References 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. Epocrates. (2018). Meniscal tear. Retrieved from https://online.epocrates.com/diseases/826/Meniscal-tear Epocrates. (2018b). Patellofemoral pain syndrome. Retrieved from https://online.epocrates.com/diseases/82711/Patellofemoral-pain-syndrome/Key- Highlights Hill, L. O. (2014). What Is Your Knee Telling You? Retrieved from https://www.webmd.com/pain-management/knee-pain/features/knee-cracks-pops#

SECOND RESPONSE

Hello Ramatou, Great post! I enjoyed reading your focused SOAP note and I do agree with your potential diagnosis. It is very important to collect history and do though physical examination and diagnostic test. Based on the presented case study, it is important to do MRI, lumbar spine X-ray and CT, myelography, blood test such as CBC, ESR, CRP, and an exclusion diagnosis is made by eliminating specific causes of lower back pain arising from neurologic compromise, neoplasia, inflammatory arthritis, fracture, and referred pain from other locations or organ systems (Epocrates, 2018). The exact cause of pain is often impossible to identify precisely, but arises from any combination of pathology involving disks, vertebrae, facet joints, ligaments, and/or muscles (Epocrates, 2018). Sciatica most commonly occurs when a herniated disk, bone spur on the spine or narrowing of the spine (spinal stenosis) compresses part of the nerve and this causes inflammation, pain and often some numbness in the affected leg (Mayo Clinic, 2018). The pain can vary widely, from a mild ache to a sharp, burning sensation or excruciating pain. Sometimes it can feel like a jolt or electric shock and it can be worse when coughing or sneezing, and prolonged sitting can aggravate symptoms which usually affects only one side of your body (Mayo Clinic, 2018). References Epocrates. (2018). Musculoskeletal lower back pain. Retrieved from https://online.epocrates.com/diseases/77834/Musculoskeletal-lower-back- pain/Diagnostic-Tests Mayo Clinic. (2018). Sciatica. Retrieved from https://www.mayoclinic.org/diseases- conditions/sciatica/symptoms-causes/syc-