NURS 6512 Week 8 Assessment of the Musculoskeletal System
Walden University NURS 6512 Week 8 Assessment of the Musculoskeletal System-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Week 8 Assessment of the Musculoskeletal System assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for NURS 6512 Week 8 Assessment of the Musculoskeletal System
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Week 8 Assessment of the Musculoskeletal System depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for NURS 6512 Week 8 Assessment of the Musculoskeletal System
The introduction for the Walden University NURS 6512 Week 8 Assessment of the Musculoskeletal System is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
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How to Write the Body for NURS 6512 Week 8 Assessment of the Musculoskeletal System
After the introduction, move into the main part of the NURS 6512 Week 8 Assessment of the Musculoskeletal System assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for NURS 6512 Week 8 Assessment of the Musculoskeletal System
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for NURS 6512 Week 8 Assessment of the Musculoskeletal System
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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NURS 6512 Week 8 Assessment of the Musculoskeletal System
NURS 6512 Week 8 Assessment of the Musculoskeletal System
Thank you for sharing your discussion with us. Your assessment and outlining of the patient’s signs and symptoms indicate an assessment of patellar tendinitis. This is the most likely diagnosis for the patient based on the patient’s history of being an athlete and prior involvement in long jumping, which could have put excessive and repetitive strain on the knee and led to inflammation. Additionally, jumps and movements from basketball could also put additional stress on the knee resulting in pain complaints.
Bursitis is also a condition secondary to tendinitis that has a similar presentation to that of the patient and is associated with overuse and trauma, leading to inflammation (Dains et al., 2019). It, therefore, is an appropriate diagnosis to examine and assess the patient to provide appropriate treatment. It is important to include it as a differential diagnosis as the location of the inflammation can differ. Therefore, treatment can be specifically directed to the inflamed location once a diagnosis is confirmed or ruled out.
The diagnosis that is least likely for the patient from the assessment would be juvenile arthritis (JA). While JA is also an inflammation of the joint that can present as pain, the characteristics of the presenting complaint are not in line with the patient’s presentation. According to Dains et al.(2019), JA can also present with fatigue, low-grade fever, and weight loss. As outlined in your discussion, the patient does not present with these findings.
The diagnosis is further less likely due to the differences in aggravation of symptoms. The patient reports worsening pain with intensive training, and after playing in games while in JA, the pain and stiffness are mostly noted in the night and morning and get better with activity. Swelling at the joint is also a common factor and was not present in this patient. JA is, therefore, the least likely assessment for this patient and the differential diagnosis I would reject.
The patient’s history of sporting activity and athletic training does justify the inclusion of chondromalacia of the patella as a differential diagnosis. According to Habusta et al.(2022), patients with chondromalacia patella do present with pain as the most common presentation and is frequently seen in patients that experience post-traumatic injuries, wear and tear to the hyaline cartilage.
The pain worsens with activities that increase stress on the patellofemoral joint, such as running and jumping, as outlined by the patient. Pain is a common symptom for most musculoskeletal conditions; therefore, it’s important to perform tests and diagnostics to rule out the possible cause of the pain to prevent misdiagnosis. Additionally, including the chondromalacia patella is important as it is sometimes diagnosed via the method of elimination.
References
Dains, J., Baumann, L., & Scheibel, P. (2019). Advanced health assessment & clinical diagnosis in primary care (6th ed.). St. Louis MO: Elsevier Mosby.
Habusta, S., Coffey, R., Ponnarasu, S., Mabrouk, A., & Griffin, E. (2022). Chondromalacia patella. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/
S.
CC (chief complaint): “I feel pain in my ankles, but the right one is more intense.”
HPI:
R.K is a 46-year-old A.A female presenting with a chief complaint of pain in her ankles. She reports that the pain in the right ankle is more intense. The ankle pain began three days ago when she was playing soccer at the women’s soccer club in her church. She states that she heard a pop sound in her right ankle when playing, which was followed by a sudden intense pain on the right ankle, and she was unable to stand on the right foot. She has, however, been able to walk on the right foot, although it is uncomfortable. R.K also reports having some degree of tenderness and swelling on the right ankle. The ankle pain is aggravated by walking and relieved to some degree by OTC Tylenol, which she takes when the pain aggravates. She rates the pain on the left ankle as 3/10 and the right ankle as 6/10 on the pain scale.
Current Medications: OTC Tylenol 1 gm for pain.
Vitamin C supplements.
Allergies: Allergic to penicillin- causes rash, hives, and itchy eyes. No known food or seasonal allergies.
PMHx: Last Influenza shot-7 months ago. Last Tetanus- 3 years ago. No history of chronic illnesses. History of an appendectomy at 34 years. History of Tonsillectomy at 7 years.
Soc Hx:
R.K is a community youth counselor and has a diploma in Counseling. The patient is married. She currently lives with her spouse and three children aged 17, 14, and 8. Her hobbies include traveling and playing football. She is the captain of the women’s soccer club in her church and is the assistant coach for the junior girls’ soccer club. She reports taking wine occasionally but denies smoking tobacco or using illicit substances. She reports having a strict diet and taking about 7 glasses of water a day. The patient states that she has an active lifestyle and takes a morning run for about 40minutes at least 5 days a week. She also plays football on weekends. Her last health exam was 2 years ago. She states that her support system is her family and sisters.
Fam Hx: Family history of HTN- mother and maternal grandfather. History of breast cancer- paternal grandmother. The elder sister has a history of Asthma. Children are alive and well.
ROS:
GENERAL: Denies elevated body temperature, reduced energy levels, chills, or weight loss/gain.
HEENT: No history of head trauma, visual changes, hearing loss, ear discharge, nasal discharge/blockage, sneezing, or pain/difficulty swallowing.
SKIN: Denies color changes, itching, or lesions.
CARDIOVASCULAR: No history of swelling, chest discomfort, heart palpitations, or dyspnea at rest or exertion.
RESPIRATORY: No history of chest pain, cough, sputum, or dyspnea.
GASTROINTESTINAL: Denies appetite changes, nausea/ vomiting, abdominal discomfort, or diarrhea/constipation.
GENITOURINARY: Denies abnormal PV discharge, dysuria, or urinary frequency/urgency. LMP-3 weeks ago.
NEUROLOGICAL: Negative for dizziness, headache, paralysis, or burning sensations in the extremities.
MUSCULOSKELETAL: Positive for ankle pain and swelling. Limitations in movement. Denies joint stiffness/pain/enlargement.
HEMATOLOGIC: No history of bleeding or blood transfusion.
PSYCHIATRIC: Denies history of mental illnesses.
ENDOCRINOLOGIC: Negative for excessive perspirations, cold/heat intolerance, excessive urination, or acute thirst.
ALLERGIES: Allergic to penicillin.
O.
Physical exam:
VITAL SIGNS: BP- 126/74; HR- 98; RR-20; Temp-98.78 F
HT-5’4; WT- 136 pounds.
GENERAL: Neat and well-groomed female in no acute distress. Alert and oriented X4. Speech is clear and goal-directed. Maintains eye contact and exhibits a positive attitude.
CARDIOVASCULAR: Negative for JVD or edema. RRR; S1and S2 audible. No gallop sounds or murmurs heard on auscultations.
RESPIRATORY: Smooth and uniform respirations. Chest clear on auscultation.
MUSCULOSKELETAL: No skin color changes at the ankles.
Left Ankle- No bruising, swelling, or loss of function. Mild tenderness at the anterior aspects of the lateral malleoli. Negative ligamentous laxity with anterior drawer and talar tilt testing. Decreased total ankle motion of 2 degrees. No bony point tenderness. No difficulty bearing weight.
Right ankle- Bruising present. Moderate tenderness at the maximal points of the anterior (ATFL) aspect of the lateral malleoli on the right ankle. Positive anterior drawer test, negative talar tilt test- moderate joint instability. Some loss of function. Decreased total ankle motion of 7 degrees. Pain with weight-bearing and walking. No bony point tenderness.
Diagnostic results:
X-ray of the right ankle: An X-ray will be required to exclude fractures.
The Ottawa ankle rules indicate that ankle radiographs should be obtained in the event of pain in the malleolar region and any of the following: Pain on the posterior margin of the distal 6 cm or apex of the lateral malleolus; Pain on the posterior margin of the distal 6 cm or apex of the medial malleolus; and Incapacity to bear weight right away after an injury and for four steps during the assessment (Wells et al., 2019).
A.
Differential Diagnoses
Acute Lateral Ankle Sprain
An ankle sprain entails an inversion-type twist of the foot, accompanied by pain and edema. Lateral ankle sprains are the most prevalent injury in physically active populations, primarily among teenagers and young adults (Herzog et al., 2019). Clinical features of ankle sprains include pain, tenderness, swelling, bruising, muscle spasm, and cold foot or paresthesia, which suggest possible neurovascular compromise (Herzog et al., 2019). According to Wells et al. (2019), ankle sprains are categorized as Grade I, II, and III. Grade I have minimal tenderness and swelling, no loss of function, decreased total ankle motion of 5 degrees and below, and swelling of 0.5 cm or below as measured by figure-of-eight testing.
Grade II is characterized by bruising, moderate tenderness, a decreased ROM between 5-10 degrees, moderate swelling of 0.5-2.0cm, and ankle instability (Wells et al., 2019). Grade III presents with bruising, significant swelling of greater than 2.0 cm, near-total loss of function, ankle instability, extreme point tenderness, and decreased ankle ROM > 10 degrees.
Acute Lateral Ankle Sprain is the presumptive diagnosis based on the positive findings in the right ankle, including bruises, some loss of function tenderness at the anterior aspect of the lateral malleoli, moderate joint instability, reduced ROM of 7 degrees, and pain with weight-bearing and walking. The right ankle symptoms are consistent with a grade II lateral ankle sprain.
Acute Achilles tendon ruptures
Individuals with an Achilles tendon rupture often present with a primary symptom of a sudden snap in the lower calf accompanied by acute, severe pain. According to Egger and Berkowitz (2017), Achilles tendon rupture commonly occurs in healthy, active, young- to middle-aged persons, mostly from 37 to 43.5 years old. Patients often report experiencing a popping or giving way feeling in their posterior heel after pushing off (Egger & Berkowitz, 2017).
Immediate pain occurs but slowly resolves, leaving a person with difficulty with plantar flexion, weight-bearing, or limping. Besides, the person cannot stand their toes on the affected side (Egger & Berkowitz, 2017). Achilles tendon rupture is a differential diagnosis based on findings of ankle pain, popping sensation that occurred during the ankle injury, and difficulties with bearing weight.
Right Ankle Fracture
While lateral ankle sprains comprise 90% of all ankle injuries, whereas an ankle fracture occurs only in 15% of the injuries, ankle fractures occur due to a twisting mechanism sustained from a low-energy injury (Lawson et al., 2018). A fractured ankle presents with severe pain, swelling, ecchymosis, and soft tissue injuries, such as abrasions and lacerations. Other features include loss of function, limited range of motion, compromised neurovascular status, and positive talar tilt and drawer testing (Lawson et al., 2018). A Right Ankle fracture is a differential diagnosis based on pertinent positives of pain, bruising, loss of function, reduced ROM, and positive talar tilt and drawer testing indicating joint instability.
References
Egger, A. C., & Berkowitz, M. J. (2017). Achilles tendon injuries. Current reviews in musculoskeletal medicine, 10(1), 72–80. https://doi.org/10.1007/s12178-017-9386-7
Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of athletic training, 54(6), 603-610. https://doi.org/10.4085/1062-6050-447-17
Lawson, K. A., Ayala, A. E., Morin, M. L., Latt, L. D., & Wild, J. R. (2018). Ankle fracture-dislocations: a review. Foot & Ankle Orthopaedics, 3(3), 2473011418765122. https://doi.org/10.1177/2473011418765122
Wells, B., Allen, C., Deyle, G., & Croy, T. (2019). MANAGEMENT OF ACUTE GRADE II LATERAL ANKLE SPRAINS WITH AN EMPHASIS ON LIGAMENT PROTECTION: A DESCRIPTIVE CASE SERIES. International journal of sports physical therapy, 14(3), 445–458. https://doi.org/10.26603/ijspt20190445
A 46-year-old man walks into a doctor’s office complaining of tripping over doorways more frequently. He does not know why. What could be the causes of this condition?
Without the ability to use the complex structure and range of movement afforded by the musculoskeletal system, many of the physical activities individuals enjoy would be curtailed. Maintaining the health of the musculoskeletal system will ensure that patients live a life of full mobility. One of the most basic steps that can be taken to preserve the health of the musculoskeletal system is to perform an assessment.
This week, you will explore how to assess the musculoskeletal system.
Learning Objectives
Students will:
- Evaluate abnormal musculoskeletal findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the musculoskeletal system
- Evaluate musculoskeletal X-Ray imaging
Learning Resources
Required Readings (click to expand/reduce)
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.
- Chapter 4, “Vital Signs and Pain Assessment” (Previously read in Week 6)
- Chapter 22, “Musculoskeletal System”This chapter describes the process of assessing the musculoskeletal system. In addition, the authors explore the anatomy and physiology of the musculoskeletal system.
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.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (“Muscle Strength Grading”) (Previously read in Weeks 1, 2, 3, 4, and 5)
- Chapter 3, “SOAP Notes”This section explains the procedural knowledge needed to perform musculoskeletal procedures.
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 13, “The Spine, Pelvis, and Extremities” (pp. 585–682)In this chapter, the authors explain the physiology of the spine, pelvis, and extremities. The chapter also describes how to examine the spine, pelvis, and extremities.
Required Media (click to expand/reduce)
Musculoskeletal System – Week 8 (12m)
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s resources, it is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 21 that relate to the assessment of the musculoskeletal system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Discussion: Assessing Musculoskeletal Pain
Photo Credit: Getty Images/Fotosearch RF
The body is constantly sending signals about its health. One of the most easily recognized signals is pain. Musculoskeletal conditions comprise one of the leading causes of severe long-term pain in patients. The musculoskeletal system is an elaborate system of interconnected levers that provides the body with support and mobility. Because of the interconnectedness of the musculoskeletal system, identifying the causes of pain can be challenging. Accurately interpreting the cause of musculoskeletal pain requires an assessment process informed by patient history and physical exams.
In this Discussion, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.
To prepare:
- By Day 1 of this week, you will be assigned to one of the following specific case studies for this Discussion. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
- 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 in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
- Review the following case studies:
Case 1: Back Pain
Photo Credit: University of Virginia. (n.d.). Lumbar Spine Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/5lumbar/01anatomy.html. Used with permission of University of Virginia.
A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform?
Case 2: Ankle Pain
Photo Credit: University of Virginia. (n.d.). Lateral view of ankle showing Boehler’s angle [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/8ankle/01anatomy.html. Used with permission of University of Virginia.
A 46-year-old female reports pain in both of her ankles, but she is more concerned about her right ankle. She was playing soccer over the weekend and heard a “pop.” She is able to bear weight, but it is uncomfortable. In determining the cause of the ankle pain, based on your knowledge of anatomy, what foot structures are likely involved? What other symptoms need to be explored? What are your differential diagnoses for ankle pain? What physical examination will you perform? What special maneuvers will you perform? Should you apply the Ottawa ankle rules to determine if you need additional testing?
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Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
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:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- 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.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 8”) with “Review of Case Study ___.” Fill in the blank with the number of the case study you were assigned.
By Day 3 of Week 8
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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6 of Week 8
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.
Submission and Grading Information
Grading Criteria
To access your rubric:
Week 8 Discussion Rubric
Post by Day 3 of Week 8 and Respond by Day 6 of Week 8
To Participate in this Discussion:
Week 8 Discussion
Assignment: Lab Assignment (Optional): Practice Assessment: Musculoskeletal Examination
A description of symptoms alone is not enough to form an accurate diagnosis of musculoskeletal conditions. Before forming a diagnosis, advanced practice nurses need to perform a physical examination. Although the musculoskeletal examination is relatively simple, it still needs to be performed multiple times before it can be mastered.
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice performing a musculoskeletal examination this week.
Note: This is a practice physical assessment.
To Prepare
- Arrange an appropriate time and setting with your volunteer “patient” to perform a musculoskeletal examination.
- Download and review the Musculoskeletal Checklist provided in this week’s Learning Resources as well as review the Seidel’s Guide to Physical Examination online media.
The Lab Assignment
Complete the following in Shadow Health:
- Musculoskeletal (Practice)
What’s Coming Up in Week 9?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine appropriate methods for assessing the cognition and the neurologic systems during your Discussion. You also will complete the last assessment, Comprehensive (Head-to-Toe) Physical Assessment. Once again, you will conduct this assessment in the Digital Clinical Experience using the simulation tool, Shadow Health. Make sure to plan your time accordingly.
Week 9 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Discussion on time.
Next Week
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Patient Information: T.J., 15 years old, African American Male
S.
CC “Both Knees hurt, especially when I walk upstairs. Sometimes I hear clicking sound along with this strange catching sensation under my knee”
HPI:
TJ is 15 -year-old African American male with bilateral patellar pain, dull in nature and localized around anterior knee area. The pain started 3 days ago and was associated with walking up and downstairs, running, and squatting. The knee pain frequently comes with a “clicking” noise and catching sensation under patella. Severity described as 7/10 .
Reports that Aleve makes it tolerable, but not completely better. Takes 1 caplet 220 mg q 8-12 hours. Exacerbating factors reported by the client are walking, jumping, and squatting.
Current Medications: Aleve 220 mg every 8-12 as needed for pain . No RX medications, no other over the counter medications.
Allergies:
No known allergies. Denies food , environmental and latex allergies.
PMHx:
Up to date on all his immunizations, last COVID booster in April 2022, last flu vaccine December 2021.
Fractured right tibia three years ago while playing football, Denies history of arthritis, rheumatic fever, or Lyme disease. Denies any prior surgeries and /or hospitalizations.
SocHx: TJ identifies himself as “heterosexual”, but he is not sexually active. He lives with his parents. Denies any tobacco , alcohol, or illicit drug use. TJ is a high school student at Thomas Jefferson High school. He enjoys playing sports , football is his favorite sport. He is a wide receiver on the school football team. TJ runs in the morning and goes to the gym during the afternoons. TJ wears his seatbelt whenever riding in a motor vehicle , reports getting 8-10 hours of sleep a night. He likes spending time with his friends and going movies.
Fam Hx: T.J parents are both still living. Dad 49 years old has history of HTN, Peptic ulcers, and gout . Mom 51-year-old has CHF and HTN. His younger brother does not have any significant health history.
ROS:
GENERAL: TJ does not have weight loss, denies fever, chills, weakness or fatigue.
HEENT: Eyes: Denies blurred or loss vision. Denies double vision. No yellowsclerae noted.
Ears, Nose, Throat: Reports no hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum production.
GASTROINTESTINAL: Denies intestinal discomfort, nausea, vomiting or diarrhea. Reports no abdominal pain or blood.
GENITOURINARY: Reports No Burning on urination.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control.
MUSCULOSKELETAL: positive for bilateral patellar pain , tenderness, and slight edema around Right and left knee.
HEMATOLOGIC: reports no anemia, bleeding or bruising.
LYMPHATICS: denies enlarged nodes and history of splenectomy.
PSYCHIATRIC: reports no depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema, or rhinitis.
O.
Physical exam:
Temp 98.6 F, Pulse 60, respirations 20and non labored. SPO2 100% on room air, BP 125/78mmhg. Weight 136 lbs, H5’8’’
Diagnostic tests:
CT scan, MRI, and Xray.
Blood Tests:
CBC (inflammation and infection screening), Erythrocyte Sedimentation Rate(Inflammation screening) , Uric Acid (rule out gout), Rheumatoid Factor (rheumatoid factor)
Differential Diagnoses
- Patellofemoral Pain Syndrome .The main cardinal feature of pain around anterior knee that worsens with descending stairs , squatting , and bending knee during weight bearing activities(Gaitonde, 2019).
- Patellar dislocation or Fracture . The main feature of this diagnosis is that occurs mostly in adults younger than 20 years old and accounts for more than 93% of the cases. It is usually the result of trauma or twisting tibia during physical activities(Ball, 2019), (Thijie,2019).
- Bursitis .It is an inflammation of the bursa that results in tenderness of the knee and knee pain. (Daines et al., 2019).
- Chondromalacia Patella(Runner’s knee) is a disease of the hyaline cartilage coating of the articular surfaces of the bone (Habusta et aal, 2019).
- Osgood-Schlatter Disease (OSD) – A condition in which the patellar ligament insertion on the tibial tuberosity ends up inflamed (Vaishya et al., 2018).
References
Gaitonde, D. Y., Ericksen, A., & Robbins, R. C. (2019). Patellofemoral Pain Syndrome. American family
physician, 99(2), 88–94.
S.
CC (chief complaint): “Lower back pain.”
HPI: D.T. is a 42-year-old Caucasian male with a chief complaint of lower back pain. He reports that the lower back pain began a month ago. He describes the pain as ‘stabbing’ and often radiates to his left leg. He reports that the pain sometimes causes numbness and weakness in the left leg. The low back pain is constant but worsens with activity, prolonged sitting, and bending. The patient has used OTC analgesic creams and Tylenol, which relieve the pain to some degree but recurs after some hours. He is concerned that the back pain may be long-term since it has already lasted a month. This will significantly interfere with his daily work activities. He rates the pain at 5/10.
Current Medications: OTC Diclofenac cream, applies twice daily. OTC Tylenol 500 mg TDS.
Allergies: Allergic to nuts- causes skin itching, redness, and swelling. No drug allergies.
PMHx: The patient has no history of chronic illnesses or admission. His immunization is not up to date. The last Flu shot was more than three years ago. Last TT- July 2018. He has received both Pfizer COVID-19 shots.
Soc Hx: D.T. is a lab technologist with a degree in Analytical chemistry. He is married and lives with his wife and two children, 15 and 10 years old. His hobbies include playing baseball and fishing. He is the captain of the baseball team in his organization. He denies smoking tobacco but reports taking a few whiskey glasses on weekends to wind up. He also denies any past or current substance use. The patient states that he is generally physically fit since he attends baseball practice 2-3 times a week. In addition, he eats balanced meals with a high composition of proteins and vegetables. He sleeps 5-6 hours a day. D.T. has private health insurance cover that also covers his family and is provided by his employer.
Fam Hx: The patient’s paternal grandfather died from prostate cancer at 82 years. His paternal grandmother died from an RTA at 85 years. His father has a history of high blood pressure. His younger brother has chronic asthma. The patient’s children have no chronic illnesses.
ROS:
GENERAL: He denies fever, weight changes, or generalized body weakness.
HEENT: Eyes: Denies eye pain, excessive tearing, or blurred vision. Ears: Denies changes in hearing or ear pain. Nose: Denies nasal discharge, sneezing, or nose bleeds. Throat: Denies throat pain or hoarseness.
SKIN: Negative for skin rash, discoloration, or bruises.
CARDIOVASCULAR: Negative for palpitations, chest tightness, swelling of lower limbs, or SOB on activity.
RESPIRATORY: He denies difficulties in breathing, cough, wheezing, or sputum.
GASTROINTESTINAL: He denies abdominal distress or changes in bowels.
GENITOURINARY: Denies urinary symptoms of penile discharge.
NEUROLOGICAL: Reports numbness and weakness in the left leg. Denies dizziness or loss of consciousness.
MUSCULOSKELETAL: Reports lower back pain and left leg pain. Limited ROM on the left leg because of pain.
HEMATOLOGIC: He denies bruising or a history of anemia.
LYMPHATICS: Denies swelling of lymph nodes.
PSYCHIATRIC: Reports increased stress due to prolonged back pain.
ENDOCRINOLOGIC: Denies excessive sweating, heat and cold intolerance, excessive thirst or hunger, or increased urination.
ALLERGIES: Hives when he eats nuts.
O.
Physical exam:
Vital Signs: BP- 122/78; HR- 86; RR-16; Temp-98.4; SPO2- 100%; HT-5’5; WT-167; BMI-27.8
GENERAL: White male patient in his 40s. The patient is calm and in no distress. He is well-groomed and appropriately dressed in casual wear. He exhibits positive facial expressions and body language. His speech is clear and goal-directed, with normal volume and rate.
CARDIOVASCULAR: Regular heart rate and rhythm.S1 and S2 are heard on auscultation. No gallop sounds or murmurs were heard.
RESPIRATORY: Smooth and even respirations. Symmetrical chest wall expansion. Lungs clear bilaterally.
NEUROLOGICAL: CN II – XII are intact; DTRs 2+ on the right leg and 1+ on the left leg. Normal sensation in the right foot; Reduced sensation in the left foot. Muscle strength 5/5 (right lower limb) 3/5 (left lower limb)
MUSCULOSKELETAL: Torso and head are upright. Normal balance when walking and standing, and the arms swing freely at the side. Straight leg raising elicits pain that radiates down the left leg when the left leg is slowly raised above 60°. On raising the right leg, the patient reports pain radiating down the left leg to the foot. ROM 4/5 in the left leg. Back ROM elicited pain with lateral rotation, forward flexion, and spine hyperextension.
Diagnostic results: Spine X-ray: Abnormal spine curve.
A.
Differential Diagnoses
Sciatica: Sciatica is characterized by pain along the sciatic nerve caused by compression of lumbar nerve roots in the lower back. Clinical features of sciatica include unilateral leg pain greater than low back pain; Pain radiating to the foot or toes; Numbness and paresthesia in the same distribution; Straight leg raising test elicits more leg pain; Localized neurology limited to one nerve root (Stynes et al., 2018). This is the most likely diagnosis due to positive symptoms of low back pain radiating to the left leg, numbness on the left foot, straight leg testing producing pain on the left foot, and crossed straight leg raising eliciting pain on the left foot.
Herniated lumbosacral disc: This is characterized by low back pain, limited trunk flexion, and sensory abnormalities at the lumbosacral nerve root distribution (Yu et al., 2022). The patient has low back pain, back pain with forward flexion, and an abnormal spine curve making Herniated lumbosacral disc a differential diagnosis.
Spinal nerve root impingement: This occurs when a spinal nerve root is compressed or irritated. The compression often causes high discomfort, like loss of sensation and weakness. When nerve root impingement occurs, the parts of the body that lie along the nerve’s path are usually the most severely affected (Berry et al., 2019). Compression of a spinal nerve root may have caused low back pain, left leg pain, and weakness. Besides, the abnormal spine curve may have irritated a nerve root.
Lumbar Spondylolisthesis: Lumbar Spondylolisthesisis characterized by intermittent and localized low back pain triggered by flexing and extending the affected segment (Dunn, 2019). The patient has low back pain and back pain with lateral rotation, forward flexion, and spine hyperextension, which are consistent with Spondylolisthesis.
Lower Back Muscle Spasm: Spasm of the lower back muscle is believed to produce secondary low-back pain and tenderness (Urits et al., 2019). This can be the cause of the patient’s lower back pain.
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This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A Review of Lumbar Radiculopathy, Diagnosis, and Treatment. Cureus, 11(10), e5934. https://doi.org/10.7759/cureus.5934
Dunn, B. (2019). Lumbar spondylolysis and Spondylolisthesis. Journal of the American Academy of PAs, 32(12), 50–51. DOI: 10.1097/01.JAA.0000604892.88852.c6
Stynes, S., Konstantinou, K., Ogollah, R., Hay, E. M., & Dunn, K. M. (2018). Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. PloS one, 13(4), e0191852. https://doi.org/10.1371/journal.pone.019185
Urits, I., Burshtein, A., Sharma, M., Testa, L., Gold, P. A., Orhurhu, V., Viswanath, O., Jones, M. R., Sidransky, M. A., Spektor, B., & Kaye, A. D. (2019). Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Current pain and headache reports, 23(3), 23. https://doi.org/10.1007/s11916-019-0757-1
Yu, P., Mao, F., Chen, J., Ma, X., Dai, Y., Liu, G., … & Liu, J. (2022). Characteristics and mechanisms of resorption in lumbar disc herniation. Arthritis Research & Therapy, 24(1), 1-18. https://doi.org/10.1186/s13075-022-02894-8
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.
ten Thije, J. H., &Frima, A. J. (2019). Patellar dislocation and osteochondral fractures. The Netherlands journal of surgery, 38(5), 150–154.
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.
Habusta, S., Coffey. R, Ponnarasu S, et al.(2022) Chondromalacia Patella.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/
Vaishya R, Azizi A, Agarwal A, et al.(2018) Apophysitis of the Tibial Tuberosity
doi:10.7759/cureus.780
Your post is well thought out and very informative. The conditions for consideration in CO’s case are patellofemoral pain syndrome, Osgood-Schlatter disease, patellar tendonitis, chondromalacia patella, and meniscal injury. Patellofemoral pain syndrome causes anterior knee pain. The pain is usually dull and worsened by exerting more pressure on the patellofemoral’s joint. Patel and Villalobos (2017) reveal that Osgood-Schlatter disease affects the growth plate of the tibia. They also show that chondromalacia patella hurts the cartilage below the kneecap (Patel & Villalobos, 2017). Then, the researchers denote patellar tendonitis to be an overuse injury that inflames the patellar tendon. Lastly, a meniscal injury is a tear to the meniscus. These conditions are synonymous with athletes who participate in sports that involve repetitive jumping or running.
Osgood-Schlatter disease and meniscal injury can be rejected as possible diagnoses. This is because the symptoms do not match the typical presentation of these conditions. According to Sanchez et al. (2022), Osgood-Schlatter disease usually causes pain and swelling below the knee joint, while meniscal injury typically causes joint line tenderness and locking or catching sensations.
Patellofemoral pain syndrome is the most probable condition here. The symptoms exhibited (bilateral anterior knee pain, clicking and catching under the patella, and aggravation of pain during running) are consistent with this condition. Also, the fact that the patient is a young male who participates in soccer and experiences relief with rest, ice application, and ibuprofen use supports this diagnosis. The physical examination findings, such as reduced range of motion and tenderness, also back this diagnosis. However, further imaging tests, such as X-rays or MRI, can be done to rule out other possible conditions and confirm the diagnosis of patellofemoral pain syndrome.
References:
Patel, D. R., & Villalobos, A. (2017). Evaluation and management of knee pain in young athletes: Overuse injuries of the knee. Translational Pediatrics, 6(3), 190-198. https://doi.org/10.21037/tp.2017.04.05Links to an external site.
Sanchez, S., Arlata, T., Arshad, S., Cheng, S., & Saunders, A. (2022, September 16). Knee injuries. The University of Texas Medical Branch. https://www.utmb.edu/pedi_ed/CoreV2/Musculoskeletal/Musculoskeletal5.htmlLinks to an external site.
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