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Respond  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.

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Knee Pain SOAP Note  

Patient Information:SJ, 15-year-old WM

S.

CC- Pain in both knees.

HPI: 15-year-old white male presents with pain in bilateral knees.  Pain onset was 1 week ago after football practice.  Pain is described as “dull”.  Associated s/s include clicking in one or both knees and a catching sensation under the patella. SJ describes pain as dull and constant, pain rated at 3 on a scale of 0-10. Pain is exacerbated by movement and relieved by rest.  

Current Medications: No medications, no OTC medications or vitamins.

Allergies: seasonal allergies only

PMHx: Immunizations current, flu shot received from PCP 10/5/19.  No previous injuries, hospitalizations, or surgeries.

Soc Hx: 10th grade student, on high school football team (offensive lineman), has played football since age 6.  Denies alcohol use, denies tobacco use, Denies use of illicit drugs.  Honor student, popular in school with many friends. Lives at home with dad and two younger sisters.  Mom is active duty/deployed currently.  Currently learning to drive in driver’s education at school.

Fam Hx: No significant medical history in parents. Maternal grandmother died at 80 of lung cancer, grandfather at 81 of MI.  Paternal grandmother has osteoarthritis, grandfather has DM.  

ROS: GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Head: denies headache, 

Eyes: Denies visual loss, blurred vision, or double vision, denies hearing loss, nasal dysfunction or sore throat.

SKIN:  denies rash or puritis.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Denies change in bowel or bladder control.

MUSCULOSKELETAL:  Knee pain, with clicking and catching sensation under the patella. Denies back pain, stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.PSYCHIATRIC:  Denies depression or anxiety.

ALLERGIES:  Denies food or drug allergies, allergy to pollen.

O.

VS: BP 123/68; P 89; RR 18; T 97.6; O2 98%; Wt 179; BMI 25.68

General- AOx4. Pt appears healthy and well nourished, athletic build.  Well groomed, no acute distress noted.

Cardiovascular- Regular rate/rhythm. S1/S2 heard, no murmurs, gallops, or rubs noted.   

Respiratory- RR even and unlabored. Clear to auscultation bilaterally with no wheezing, rales, rhonchi, or crackles.

Musculoskeletal- joint stability normal in upper extremities, no tenderness to palpation.  Lower bilateral popliteal tenderness upon palpation, Rt quadricep angle 18 degrees, Lt quadricep angle 20 degrees.  Bilateral inflammation present in the distal extensors.

Diagnostic results: CBC: WBC-5.9 Hgb- 16.1  Hct- 49 Platelet count- 210, X-ray McMurry test negative, Lachman test negative, MRI- negative for meniscus tear, negative for ACL tear, negative for CP.

A.Patellar tendinitis- This overuse syndrome is characterized by inflammation in the distal extensors of the knee joint (Dains, Baumann, & Scheibel, 2019). Patellar tendinitis is more common in athletes who habitually place excessive strain on their knees from jumping or running (Dains, Baumann, & Scheibel, 2019). Determine the quadriceps angle by measuring the angle between the center of the patella to the anterior superior iliac spine and from the center patella to the tibial tubercle (Dains, Baumann, & Scheibel, 2019). An angle greater than 10 degrees in males and 15 degrees in females suggests patellar tendinitis (Dains, Baumann, & Scheibel, 2019). People affected complain of dull, achy knee pain that may have associated clicking or popping (Dains, Baumann, & Scheibel, 2019).

Medial meniscus tear- clinically examined with McMurray’s test and joint line tenderness for clinical diagnosis of medial meniscus tear (Gupta, Mahara & Lamichhane, 2016). The presence of pain and/or click/snap/clunk/thud was considered positive for the McMurray’s test. Joint line tenderness was tested in 90 degree of knee flexion (Gupta, Mahara & Lamichhane, 2016).Anterior cruciate ligament tear- Patients with ACL tears typically present with acute injury, sometimes with an associated “pop,” a sensation of tearing, the immediate onset of effusion, or any combination thereof.  Better tests are the Lachman test and the pivot-shift test, which have reported respective sensitivities of 0.87 and 0.49 and specificities of 0.97 and 0.98 (Volker & Karlsson, 2019). The pivot-shift test is a dynamic test of the rotatory laxity of the knee that produces subluxation and reduction (felt as a “clunk”) of the lateral tibial plateau (Volker & Karlsson, 2019). Although plain radiography is often the first diagnostic step after the physical examination to rule out fracture, dislocation, or both, magnetic resonance imaging (MRI) is strongly recommended as part of the diagnostic evaluation, given its reported high sensitivity and specificity (97% and 100%, respectively) for the detection of ACL injury (Volker & Karlsson, 2019).

Acute leukemia- Leukemia is the most common cancer in children, and bone and joint pain is the most common presenting complaint (Dains, Baumann, & Scheibel, 2019). The bone pain is diffuse and nonspecific and may extend to adjacent joints (Dains, Baumann, & Scheibel, 2019). Laboratory findings may show the WBC count as elevated, depressed, or normal; severe anemia is common, as is a depressed platelet count (Dains, Baumann, & Scheibel, 2019). Radiographs of the limb at the distal end of the femur and the proximal end of the tibia show abnormal areas of radiolucency (Dains, Baumann, & Scheibel, 2019). 

Chondromalacia Patellae- Chondromalacia patellae (CP) represents a spectrum of abnormalities, including softening, swelling, fraying and erosion of the hyaline cartilage overlying the patellae and sclerosis of underlying bone (Harman et al., 2003). Patients with CP experience pain as the articular cartilage begins to degenerate and abnormal stresses are transferred from the elastic, shock-absorbing cartilage to the subchondral bone (Harman et al., 2003).  MRI, with its multiplanar capabilities, excellent soft tissue resolution and noninvasive nature, has been studied in the evaluation and staging of chondral lesion in the knee (Harman et al., 2003)

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

                                              References

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. Gupta, Y., Mahara, D., & Lamichhane, A. (2016). McMurray’s Test and Joint Line Tenderness for Medial Meniscus Tear: Are They Accurate? Ethiopian Journal of Health Sciences, 26(6), 567–572. https://doi-org.ezp.waldenulibrary.org/10.4314/ejhs.v26i6.10Harman, M., Ipeksoy, U., Dogan, A., Arslan, H., & Etlik, O. (2003). MR arthrography in chondromalacia patellae diagnosis on a low-field open magnet system.Clinical Imaging, 27(3), 194-9. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1016/S0899-7071(02)00521-1 Volker, M., & Karlsson, J. (2019). Anterior cruciate ligament tear. The New England Journal of Medicine, 380(24), 2341-2348. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1056/NEJMcp1805931

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