Case Study For Dull Pain In Both Knees Assignment
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Discussion Response
Hello, I think chondromalacia patellae, or runner’s knee, is the primary diagnosis of the patient’s condition because its description is consistent with the patient’s symptoms. For example, the patient feels dull pain rated four on a scale of 1 to 10 with occasional crackling sound in one or both knees, and the pain intensifies when playing baseball. Health professionals may diagnose the condition as runner’s knee, considering the swelling observed in the left knee during physical examination.
Health professionals would likely rule out medial meniscus tear because its description is not entirely consistent with the patient’s symptoms and observations from the physical examination. For example, while pain and swelling may be characteristic of meniscus tears, the patient can walk steadily without assistance, yet meniscus tears cause limping (Johns Hopkins Medicine, 2022)Case Study For Dull Pain In Both Knees Assignment. Further, the patient explains that he first experienced the pain two weeks ago during sports and was able to tolerate the pain during this period while engaging in additional sporty activities, which is uncharacteristic of meniscus tear experiences. Finally, the patient feels pain in both knees, yet it is unlikely that tears would occur in both knees as the condition develops upon sudden twisting when landing on the ground.
I agree that health professionals will likely rule out osteoarthritis, patellar dislocation, and Ewing’s sarcoma because their diagnostic criteria are not entirely consistent with the patient’s symptoms and physical examination outcomes. For example, osteoarthritis pain worsens progressively with activity and inactivity and may not get better with rest (Hsu & Siwiec, 2022) Moreover, the damage to the surrounding tissue impairs normal gait. Similarly, patients with patellar dislocation cannot walk or engage in sports after the injury (Hayat et al., 2022). Finally, although Ewing’s sarcoma occurs commonly among teenagers, health professionals will likely rule it out because the patient presents with pain in both knees, denies weight loss, and does not report tingling, fatigue, or fever (Johns Hopkins Medicine, 2022)Case Study For Dull Pain In Both Knees Assignment. Indeed, health professionals will likely perform imaging tests to confirm the diagnosis.
References
Habusta SF, Coffey R, Ponnarasu S, et al. Chondromalacia Patella. [Updated 2022 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/
Hayat Z, El Bitar Y, Case JL. Patella Dislocation. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538288/
Hsu H, Siwiec RM. Knee Osteoarthritis. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507884/
Johns Hopkins Medicine. (2022). Ewing Sarcoma in Adults. Johns Hopkins Medicine https://www.hopkinsmedicine.org/health/conditions-and-diseases/sarcoma/ewing-sarcoma-in-adults
Johns Hopkins Medicine. (2022). Torn Meniscus. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/torn-meniscus Case Study For Dull Pain In Both Knees Assignment
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male)Case Study For Dull Pain In Both Knees Assignment. You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance)Case Study For Dull Pain In Both Knees Assignment.
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe Case Study For Dull Pain In Both Knees Assignment.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
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Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Dull Pain In Both Knees Assignment
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study For Dull Pain In Both Knees Assignment
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