Patient Information:
XX, 15yo, Male
S.
CC: “Dull pain, both knees”
HPI:
Location: Both knees (would ask him to point to the exact location)
Onset: NA (would ask if onset was sudden or gradual, was he doing an activity when it occurred)
Character: Dull, catching, clicking
Associated signs and symptoms: NA (would ask if the pain wakes him up at night, what activities are limited due to the knee pain, can he straighten or bend the knees)
Timing: NA (would ask when the pain occurs)
Exacerbating/ relieving factors: NA (would ask what makes it worse, what makes it better)
Severity: NA (would have pain rated on a scale of 0-10)
Current Medications: NA (would ask what medication he is on if any)
Allergies: NA (would ask if any medication or food allergies)
PMHx: NA (would ask about general health, past illnesses, past surgeries, hospitalizations, immunizations, any blood transfusions, any psych history)
Soc Hx: NA (would ask if he works, and where, does he play sports and if so what and how often, does he smoke, does he drink alcohol, does he do any illicit drugs, does he drink caffeine, if so how much and how often for each, has he lost or gained any weight, does he follow a specific diet, and what about exercise) I would also ask if he uses sports safety equipment if he plays in sports, does he wear a seatbelt, does he ride with others that may be impaired by drugs or alcohol.
Fam Hx: NA (would ask about parents, grandparents, sibling health history and any deaths, ask about cancer, cardiac diseases, diabetes)
ROS:
GENERAL: NA (would ask if any weight loss, fever, chills, weakness or fatigue)
HEENT: NA Eyes, Ears, Nose, Throat (would ask if any drainage, problems, blurred vision, problems swallowing etc.)
SKIN: NA (would look for skin rashes, moles, or open wounds)
CARDIOVASCULAR: NA (would ask about heart problems, blood pressure, swelling to lower extremities)
RESPIRATORY: NA (would ask about shortness of breath, cough or sputum)
GASTROINTESTINAL: NA (would ask about anorexia, nausea, vomiting or diarrhea. abdominal pain or blood)
GENITOURINARY: NA (would ask about burning on urination, would address sexual activity/protection)
NEUROLOGICAL: NA (would ask about headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, changes in bowel or bladder control)
MUSCULOSKELETAL: unilateral to bilateral knee pain, clicking, and catching under the patella, (would further ask if he had any limping at time of knee pain, any back pain, joint pain or stiffness)
HEMATOLOGIC: NA (would ask if any anemia, bleeding or bruising)
LYMPHATICS: NA (would ask if patient noticed any enlarged nodes or has a history of splenectomy)
PSYCHIATRIC: NA (would ask if any history of depression or anxiety)
ENDOCRINOLOGIC: NA (would ask if any sweating, cold or heat intolerance, polyuria or polydipsia)
ALLERGIES: NA (would ask if history of asthma, hives, eczema or rhinitis)
O.
Physical exam: knee checks I would perform are:
- Bulge Sign: Applying lateral pressure to the area adjacent of the patella will be positive if fluid is present on medial knee joint, also palpating this area will allow for assessment of patellar tendinitis. (Dains, Baumann, and Scheibel, 2016)
- McMurray Maneuver: With patient supine, maximally flex knee and hip; externally and internally rotate tibia with one hand on distal end of tibia: with other hand, palpate joint to test for meniscus injury if palpable or audible click is heard. (Dains, Baumann, and Scheibel, 2016)
- Collateral Ligament Test: Applying medial or lateral pressure with the knee flexed 30 degrees and when it is extended. If sprained it will show laxity in movement and no solid end points. (Dains, Baumann, and Scheibel, 2016)
- Lachman Test: With knee flexed 30 degrees, pull tibia forward with one hand while other hand stabilizes femur. A positive test is a mushy or soft end feel when tibia is moved forward, indicating damage to anterior cruciate ligament. (Dains, Baumann, and Scheibel, 2016)
- Monitor patient gait, ability to do stairs, or kneel, monitor for flexion and extension pain to look for tibial tubercle injury related to Osgood-Schlatter disease. (Dains, Baumann, and Scheibel, 2016)
Overall look of knee color, swelling, temperature of skin to palpation, and patient vitals to monitor for fever.
Diagnostic results:
Complete Blood Count to monitor white count to look for infection. Estimated sed rate to look for inflammation. (Dains, Baumann, and Scheibel, 2016)
Radiography 4 view film of knee for an anteroposterior, lateral, tunnel, and a 30-degree sunrise view of the patella. (Dains, Baumann, and Scheibel, 2016) Radiography films would help view knee, ligaments, and bone to view for injury. May also need a knee Ultrasound. Use of magnetic resonance imaging or computed topography scan would be utilized if no answers obtained from physical exam and preliminary diagnostic tests.
A.
Differential Diagnoses:
- Patellar Tendinitis: Jumpers knee, overuse of knee, inflammation of distal extensors of the knee joint. Excess strain on knees from jumping and running. Patient experiences dull, achy knee pain, associated with clicking or popping, can involve one or both knees. (Dains, Baumann, and Scheibel, 2016) Patellar tendinopathy is a common musculoskeletal dysfunction in athletes with 11-14% of non-elite players of basketball, volleyball, and handball per Scattone Silva, Nakagawa, Ferreira, Garcia, Santos, and Serrao (2016). They further share 53% quit sport careers due to it, as the impaired knee extensor muscles cause tendon overload and the recommendation is for strengthening of quadriceps and hamstring muscles to help distribute force equally with jumping and increasing the ankle dorsiflexion as these contribute to patellar tendinopathy
- Meniscus Injury: A medial meniscus injury is more common than a lateral meniscus tear and is generally obtained due to twisting injuries, the patient will have problems with flexion, and bearing weight they will experience clicking and catching of the knee which can be swollen and tender. (Dains, Baumann, and Scheibel, 2016) This will generally affect one knee rather than both, especially at the same time. Mosich, Lieu, Ebramzadeh, and Beck, (2018) share 80-90% occur with athletic activity and meniscus repair seen in two studies showed a 37% mean re-tear rate within 17 months. They further share success rate reported at 80% with simple tears and arthroscopy is the surgical repair choice. They state 889% return to sports at the pre-injury level with isolated meniscus tears, and repair is better than meniscectomy due to increased risks of osteoarthritis in the long run.
- Medial Collateral Ligament Sprain: Caused by valgus stress to the knee, the patient typically limps after the injury. Andrews, Mckean, and Ebraheim (2017) share the medial collateral ligament is one of four major ligaments that supports the knee, stabilizes the medial knee joint, protects of valgus stress, rotational forces and anterior translational forces on the tibia. They further share 40% of all knee injuries of this type are related to trauma and change in speed direction of knee activity the patient can experience the knee giving out or popping, then the joint fills with blood. They also state the patient can return to previous activity without treatment in 10-20 days, but injury is graded and if a grade 3 can recur and may require surgery as other ligaments may be involved and these recur at a rate of 23%.
- Anterior Cruciate Ligament (ACL) Tear: Occurs if the knee is twisted or hyperextended causing stretching or tearing of ligaments, with the ACL in the center of the knee, the patient hears a pop, giving way of the knee and swelling. (Dains, Baumann, and Scheibel, 2016) The ACL is the 2nd ligamentous restraint of the knee to abduction per Bates, Nesbitt, Shearn, Myer, and Hewett (2015), the medial cruciate ligament ruptures 20-40% of the time with the ACL injury. They further share the ACL restrains 85% of the anterior force of the knee. This type of injury can take 6-12 months to heal, typically requires surgery in 75% of patients. (Bates et al., 2015) Bates et al. further shares there are negative effects within 15 years of surgery and 70% occur during non-contact sports with rapid deceleration and change in direction.
- Osgood-Schlatter Disease: Found in adolescent males most often, patient experiences pain and swelling in the anterior part of the tibial tubercle. Strenuous activity of the quadricep muscle causes limping by the patient, and pain that worsens with kneeling or climbing stairs, the knee may be warm to touch, and tender at the tibial tubercle with increased pain on flexion and extension while having a normal knee joint. (Dains, Baumann, and Scheibel, 2016) Traction of the patellar tendon at its attachment of tibial tubercle mostly is sports related with running and jumping, the patient can use ice, non-steroidal anti-inflammatories, and exercises that strengthen the quadriceps and hamstring muscles per Indiran, and Jagannathan (2018). This is typically found in males more than females 215 are adolescent athletes compared with 4.5% non-athletes per Kalbiri, Tapley, and Tapley (2014). They further share the injuries are related to earlier induction to sports, decreased time between sporting seasons, and performance pressure that lead to overuse. They also share patients can be tested using the single leg squat as this is difficult to do with this injury. Utilizing straight leg raises, wall squats, and rope jumping after healing can strengthen quadricep and hamstring muscles and the use of a intra patella strap can help strengthen the knee for mobility.
P. NA
References
Bates, N. A., Nesbitt, R. J., Shearn, J. T., Myer, G. D., & Hewett, T. E. (2015). Relative strain in the anterior cruciate ligament and medial collateral ligament during simulated jump landing and sidestep cutting tasks. American Journal of Sports Medicine, 43(9), 2259-2269. doi:10.1177/0363546515589165
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.
Indiran, V., & Jagannathan, D. (2018). Osgood-Schlatter Disease. New England Journal of Medicine, 378(11), e15. doi:10.1056/NEJMicm1711831
Kabiri, L., Tapley, H., & Tapley, S. (2014). Evaluation and conservative treatment for Osgood-Schlatter disease: A critical review of the literature. International Journal of Therapy & Rehabilitation, 21(2), 91-96.
Mosich, G. M., Lieu, V., Ebramzadeh, E., & Beck, J. J. (2018). Operative treatment of isolated meniscus injuries in adolescent patients: A meta-analysis and review. Sports Health, 10(4), 311-316. doi:10.1177/1941738118768201
Scattone Silva, R., Nakagawa, T. H., Ferreira, A. G., Garcia, L. C., Santos, J. E., & Serrão, F. V. (2016). Lower limb strength and flexibility in athletes with and without patellar tendinopathy. Physical Therapy in Sport, 20, 19-25. doi:10.1016/j.ptsp.2015.12.001
Post 2
Patient Information:
XX, 42, Male
S.
CC: “lower back pain”
HPI: 42 year old male who reports having pain in his lower back for the past month, which radiates to his left leg at times.
Location:lower back
Onset: 1 month
Character: unknown
Associated signs and symptoms:radiates to left leg at times
Timing: unknown
Exacerbating/ relieving factors: unknown
Severity: unknown
Current Medications: Unknown
Allergies: Unknown
PMHx: Unknown
Soc Hx: Unknown
Fam Hx: Unknown
ROS:
GENERAL: Unknown
HEENT: Unknown
RESPIRATORY: Unknown
GASTROINTESTINAL: Unknown
GENITOURINARY: Unknown
NEUROLOGICAL: Unknown
MUSCULOSKELETAL: Unknown
LYMPHATICS: Unknown
PSYCHIATRIC: Unknown
ALLERGIES: Unknown
O.
HEENT: Unknown
RESPIRATORY: Unknown
GASTROINTESTINAL: Unknown
GENITOURINARY: Unknown
NEUROLOGICAL: Unknown
MUSCULOSKELETAL: Unknown
LYMPHATICS: Unknown
Diagnostic results: Please note, diagnostic testing is not warranted without the first four week for the onset of back pain if neurological symptoms are not present (Dains, Baumann, & Scheibel, 2016, p. 295).
- Straight leg raising (SLR): Assess for sciatic nerve root pain or a herniated disk (Dains, Baumann, & Scheibel, 2016, p. 293).
- Radiographic pictures: Will rule out fracture, tumor, osteophytes, or a vertebral infection (Dains, Baumann, & Scheibel, 2016, p. 295).
- Bone scan: Will look at blood flow and bone formation. Will show inflammation, infiltrations, and occult fractures. Can determine the risk of osteoporosis (Dains, Baumann, & Scheibel, 2016, p. 295).
- Electromyography: Will assess nerve root compression and the functionality of peripheral nerves (Dains, Baumann, & Scheibel, 2016, p. 295).
- Magnetic resonance imaging (MRI): Will measure soft tissue that would reveal a herniated disk, tumor, or a spinal cord pathologies (Dains, Baumann, & Scheibel, 2016, p. 295).
- Computed tomography (CT): Will aid in bone visualization (Dains, Baumann, & Scheibel, 2016, p. 295).
- Complete blood count (CBC): Will detect signs of anemia or infection that could be related to the development of an infection or tumor causing back pain (Dains, Baumann, & Scheibel, 2016, p. 295).
A.
Differential Diagnoses
- Sciatica- Diagnosing is primarily done through history and physical exam. Often presents with lower back pain with additional pain in the leg. Most often caused by a herniated disk. Because of our patient presents with both of these symptoms, sciatica would be the probable diagnosis. The sciatic nerve would be the affected nerve (Verwoerd et al., 2014).
- Herniated disk- Classified as lower back pain that can cause sciatica. Numbness and weakness are not typically experienced (Verwoerd et al., 2014).
- Spinal fracture- Most commonly occurs in relation to a fall or heavy lifting. Found more frequently in the elderly population and could indicate an underlying diagnosis of osteoporosis (Enthoven et al., 2016).
- Spinal metastasis- Would expect weight loss, fatigue, and anemia in conjunction with the back pain. A detailed health history would reveal other existing cancer or possibly a family history of cancer. Sensory and motor defects are typically present (Hohenberger et al, 2018).
- Cauda Equina Syndrome- Develops from a lumbar herniated disk. Low back pain, bladder and bowel dysfunction, sexual dysfunction, and lower extremity sensory motor loss can be developing symptoms. Emergent intervention is necessary for this diagnosis (Ahad, Elsayed, & Tohid, 2015).
P.
Not required.
Additional Interview Questions
Obtain vital signs and determine if a fever is present. The presence of a fever could indicate an infectious or inflammatory process. Also determine if there has been any recent weight loss, intravenous drug use, or underlying immunosuppression (Dains, Baumann, & Scheibel, 2016, p. 288).
Determine if the patient has undergone any recent trauma to the spinal cord that could have caused a fracture, dislocation, or sore muscles. Further assessment of the patient’s occupation and any possible strain to the lower back during day to day actives. Also inquiring about any existing medical conditions that the patient may have (Dains, Baumann, & Scheibel, 2016, p. 289).
Systemic diseases, such as cancer and fibromyalgia should be ruled out. Furthermore, if the patient has an underlying diagnosis of cancer, tumor development on the spinal cord is at an increased risk (Dains, Baumann, & Scheibel, 2016, p. 289).
Assessing the patient’s bowel and bladder function could signify nerve root compression related to a herniated disk, a nerve root entrapment, spinal stenosis, infection, or tumor. The incontinence of the bowel and bladder could indicate the presence of cauda equina syndrome (Dains, Baumann, & Scheibel, 2016, p. 290).
A complete list of the patient’s medications could lead the advanced practice registered nurse (APRN) to possible lower back pain causes. For example, if the patient was using illegal intravenous drugs, an infectious process could have set it and could be affecting the back (Dains, Baumann, & Scheibel, 2016, p. 290).
Obtaining detailed information about the back pain will aid the APRN in the cause of the back pain. Further information to obtain would include, characteristic of the pain, aggravating factors, and alleviating factors. A thorough assessment would also include questions asked about balance and gait changes. The APRN would also ask about the presence of numbness and tingling in the back or other extremities (Dains, Baumann, & Scheibel, 2016, p. 291-292).
Additional Physical Examination
Observe the patient’s overall appearance and movement. By watching the patient move you can determine asymmetrical movement that may be related to his underlying diagnosis. Vital signs will help determine an infectious process. Assess the skin looking for signs of a tumor or dermal cyst. Abnormalities of the head, eyes, ears, norse, and throat could signify an infectious process. By inspecting the back and extremities the APRN can assess for spinal alignment symmetry of both sides of the body. Percussion of the back and spine could uncover scolioses and would identify tenderness.Range of motion testing will help identify lumbar mobility. Furthermore, an examination of the hip should include mobility, muscle strength, muscle circumference, neurological sensory function, deep reflexes and an assessment to the abdomen (Dains, Baumann, & Scheibel, 2016, p. 294-295).
References
Ahad, A., Elsayed, M., & Tohid, H. (2015). The accuracy of clinical symptoms in detecting
cauda equina syndrome in patients undergoing acute MRI of the spine. Neuroradiology
Journal, 28(4), 438-442. doi:10.1177/1971400915598074
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.
Enthoven, W. M., Geuze, J., Scheele, J., Bierma-Zeinstra, S. A., Bueving, H. J., Bohnen, A. M.,
& … Luijsterburg, P. J. (2016). Prevalence and “red flags” regarding specified causes of
back pain in older adults presenting in general practice. Physical Therapy, 96(3),
305-312. doi:10.2522/ptj.20140525
Hohenberger, C., Schmidt, C., Höhne, J., Brawanski, A., Zeman, F., & Schebesch, K. (2018).
Effect of surgical decompression of spinal metastases in acute treatment – Predictors of
neurological outcome. Journal Of Clinical Neuroscience: Official Journal Of The
Neurosurgical Society Of Australasia, 5274-79. doi:10.1016/j.jocn.2018.03.031
Verwoerd, A. H., Peul, W. C., Willemsen, S. P., Koes, B. W., Vleggeert-Lankamp, C. M., el
Barzouhi, A., & … Verhagen, A. P. (2014). Diagnostic accuracy of history taking to assess
lumbosacral nerve root compression. The Spine Journal: Official Journal Of The North
American Spine Society, 14(9), 2028-2037. doi:10.1016/j.spinee.2013.11.049
