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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?

Assessing Musculoskeletal Pain: Knee

Patient Initials: MA    Age: 15 years  Gender: Male

SUBJECTIVE DATA: 

Chief Complaint (CC):  “My knees hurt, panful and with clicking sound. I experience catching sensation under the patella. ”  The additional history will be assessed by asking questions related to the onset of the pain in terms of acute or gradual, duration of the pain and its associated symptoms and previous treatment for the pain.

History of Present Illness (HPI): MA is a high school sophomore who came to the doctor complaining of knee pain.  He is an active basketball player for his school team. He started experiencing knee pain in the last week. He claims to be suffering clicking sounds from both knees. 

Location: bilateral knees.

Onset: Eight days while playing basketball.

Character: Dull intermittent pain.

Associated signs and symptoms: A catching sensation under kneecaps.

Timing: For the past 8 dyas.

Exacerbating/ relieving factors: gets worst while patient treks to school.  The pain subsides with mediciation rest and ice pack.

Severity: 7 on a pain scale of 1-10 after pain medication Ibuprofen 200mg 2 tabs orally was taken and 10/10 worst pain level after a trek to school.

Medication: Ibuprofen.

Allergies: No allergy to medication but allergic to shellfish.

Past Medical History (PMH): The patient sprained his left knee four months ago, and history of Rheumatic fever during his early childhood.

Past Surgical History (PSH): No history of medical surgery.

Sexual/Reproductive History:  None. The patient is not sexually active. 

Personal/Social History: Denies smoking, drinking alcohol, or using any other drugs.

Immunization History: All immunizations are up to date as per the parents. Received flu vaccine 10/5/19. 

Significant Family History:  MA lives with his parents. Both grandfathers have diabetes, his mother is obese. His two other siblings are healthy. The family has a history of obesity.

Review of Systems: MA has presented a complaint of dull knee pain that he experiences in both knees.  The pain is clicking and accompanied with a catching sensation under the patella.  The pain mostly persists during physical activity.

OBJECTIVE DATA: 

General: MA is a healthy 15 years old who has maintained a healthy body. MA is alert and oriented and very active in school when it comes to basketball and running. No complaint of pain in other joints.

HEENT:  He denies headache or any sign syncope. Denies loss of vision, has no hearing loss and last visited dentist two months ago.

RESPIRATORY:  MN denies a cough and shortness of breath.

Cardiac: No irregular heart rate noted

Extremities: Both knees show no sign of edema and tenderness, but the knees are slightly misaligned with the thigh bone.

Physical Exam: Vital signs: BP 112/72, P 76, regular, T 98.6 temporal, RR 18, and regular. His current weight is 165. Height 5 feet 8inch.

Cardiovascular/Peripheral Vascular: Heart rate is regular and has good S1, S2; no S3 or S4; no murmur. There is no pedal edema or erythema.

Genitourinary: No abnormalities reported with frequencies urination

Psychiatric: The patient appears to be alert and oriented x3.  Denies depressive mode

Neurologic: Alert and oriented to persons, place, and time.

Skin: Skin is intact and is warm to touch and appears moist.

Hematologic:  No evidence of clotting conditions reported.

Allergic/Immunologic: Allergy to shellfish.

Manual Muscle Testing: Knee flexion 5/5, pain. Knee extension 5/5, painful. Knee ER 5/5, Knee IR 5/5.

Musculoskeletal Tests:  The patient can perform a regular activity such as walking, bending the knee with slight discomfort noted.

Diagnostic tests: Computerized tomography (CT) scan, Bilateral Knee X-ray, CBC, and Magnetic resonance imaging (MRI).

The practitioner must assess for abnormalities during musculosketal examination. The lower extremities must be examined for alignment with the edge between the femur and tibia under 15 degrees (Ball, Dains, Flynn, Solomon, and Stewart, 2015). Range of motion must be assessed in patients with suspected fracture (Ball et al., 2015). McMurray test to rule out tear of the meniscus, Varus-valgus stress test to check for knee stability, and Lachman test for anterior cruciate ligament.  The three diagnostic test will help to examine the tissues around the knee, check for patella abnormalities or dislocation, and rule out knee fracture.

ASSESSMENT/Differential Diagnosis:

Priority diagnosis would be Osgood Schlatter Disease: A common cause of knee pain in adolescents. This in an inflammation underneath the knee where the ligament from the patellar tendon attaches to the tibia. 

Differential Dx:  These include

  1. Osteogenic Sarcoma – This condition is associated with people age 10-25 yrs, and it is characterized by intermittent pain (Ryan, Maryam, & Hue, 2016).
  2. Patellar dislocation. This condition is associated with shifting of the knee patella from its normal positioning and is characterized by pain in the patella (Rudavsky & Cook, 2014)
  3. Patella fracture. The condition is where the kneecap suffers breakage or cracking and result to pain in the knee, accompanied by swelling and bruising around the knee (Reinking, 2016). Though the patient does not have all these symptoms, it is a probability.
  4. Medial meniscus– This condition is associated with knee pain, difficulty flexing, clicking, or catching of the knee movement, just like in the case of the patient (Wu et al. 2018).
  5. Patellar chondromalacia. This is when the cartilage in the kneecap gets worn by age or injury and is accompanied by discomfort of the inner knee and pain that aggravate from the physical activity just like in the case of the patient (Pak, Lee, & Lee, 2013).

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.

Rudavsky, A., & Cook, J. (January 01, 2014). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy, 60, 3, 122-129.

Reinking, M. F. (January 01, 2016). Current concepts in the treatment of patellar tendinopathy. International Journal of Sports Physical Therapy, 11, 6, 854-866.

Pak, J., Lee, J. H., & Lee, S. H. (January 01, 2013). A novel biological approach to treat chondromalacia patellae. Plos One, 8, 5.

Wu, J. L., Lee, C. H., Yang, C. T., Chang, C. M., Li, G., Cheng, C. K., Chen, C. H., Lai, Y. S. (January 01, 2018). Novel technique for repairing posterior medial meniscus root tears using porcine knees and biomechanical study. Plos One, 13, 2.

Ryan, A. D., Maryam, M., & Hue, H. L. (December 01, 2016). Review of Osteosarcoma and Current Management. Rheumatology and Therapy, 3, 2, 221-243.

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