Assessment of Musculoskeletal System Essay
Assessment of Musculoskeletal System Essay
Focused SOAP Note Template
S (subjective)
Chief complaint: pain on both knees
History of the presenting complaint: T.F is a 15 years old male who presents with knee joint pain on both knees for one week. The pain was of gradual onset, dull at the frontal patellar. The pain is aggravated by exertion, rising from a sitting position, climbing up and downstairs, jumping, and running. He reports that the pain is on and off and at times it is associated with a catching sensation under the patellar. He denies a history of joint stiffness, swelling, numbness, and trauma. Assessment of Musculoskeletal System Essay
Past Medical History: The patient was previously admitted to the hospital due to a patellar tendon rupture
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Current Medications: T.F takes Tylenol 500mg when he is in pain.
Allergies: the patient is allergic to sulfur
Social and Substance History: T.F is a young jovial male who actively participates in basketball and athletics. He is a bright student in the class and relates well with students, teachers, and parents. He neither drinks alcohol nor smokes cannabis and tobacco.
Family History: he is the 5th born in a family of six. His parents and siblings are alive and healthy. No history of chronic illnesses in the family.
Surgical History: the patient has undergone a tendon repair surgery
Review Of Systems
General: The patient denies a history of general body malaise and weight loss
Head: he denies history of a headache, dizziness
EENT (eyes, ears, nose, and throat): he denies a history of lacrimation and blurring of vision, running nose, sore throat, and earache.
Skin: No rash or itching.
Cardiovascular: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
Respiratory: No shortness of breath, cough, wheezing, or sputum.
Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
Neurological: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Assessment of Musculoskeletal System Essay
Hematologic: No anemia, bleeding, or bruising.
Lymphatic: No enlarged nodes. No history of splenectomy.
Endocrinology: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
O (objective)
Physical examination: the patient walked in limping with a normal gait. He is in a fair general condition. No notable pallor, jaundice, cyanosis, edema, dehydration, and lymphadenopathy. His vitals are the temperature at 36.1, blood pressure at 110/69mmHg, and pulse rate at 80beats per minute. His knees have a normal physique, shape, color, size, muscle bulk, and contour. Both joints have normal skin temperature, no swelling, and tenderness. The tibia tuberosity is of normal size and shape and slightly tender. There is crepitus on the knee joints, increased hip adduction, and decreased extensor movement.
Diagnostic tests: imaging studies appropriate for this patient are X-ray sunrise views anterior-posterior and lateral. A CT scan and MRI are important in visualizing the patellar cartilage. According to Haveri, S. (2020), arthroscopy helps to determine the patella-femoral syndrome by visualizing the joint cartilage.
A (assessment)
Differential diagnoses: Differential diagnoses are patella-femoral syndrome, patellar tendonitis, and patella-femoral arthritis. Patellar tendonitis is the inflammation of the patellar tendon due to injury. It is associated with swelling and a burning feeling in the kneecap. The pain interferes with physical and sporting activity (Mersmann, et al, 2019). Patellar-femoral arthritis is the inflammation of the patellar as a result of wearing off of the patellar. It presents with knee joint pain, swelling, increased local temperature, and crepitus (Sanders, et al, 2017). Patellar-femoral syndrome is pain at the frontal knees and knee cap associated with trauma and commonly occurs in athletics. It presents with pain when exercising, pain when bending knees like climbing stairs and squatting (Haveri, S. 2020). Pain after sitting for an extended time and cracking sounds are the presenting factors. The actual diagnosis for the patient is a patellar-femoral syndrome.
P (plan)
Pharmacological
Tylenol 500mg three times a day
Non-pharmacological
Stretching the quadriceps, patellar tapping techniques, proper footwear, foot orthoses to return to the sub-talar joint in a neutral position, soft knee braces, and occupational therapy. Assessment of Musculoskeletal System Essay
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?
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? We are assigned case 3 knee pain. Another SOAP note that you are excellent at. I will upload the template and an example of this discussion. Discussion: Assessing Muscoskeletal Pain 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 provide 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. Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, 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. Case 1: Back Pain 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 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 Ottowa ankle rules to determine if you need additional testing? 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? To prepare: 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 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 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. Assessment of Musculoskeletal System Essay
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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 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.
References
Haveri, S. (2020). Patella clunk syndrome in posterior stabilised total knee arthroplasty. International Journal of Orthopaedics, 6(01), 74-77.
Mersmann, F., Pentidis, N., Tsai, M. S., Schroll, A., & Arampatzis, A. (2019). Patellar tendon strain associates to tendon structural abnormalities in adolescent athletes. Frontiers in physiology, 10, 963.
Sanders, T. L., Pareek, A., Johnson, N. R., Stuart, M. J., Dahm, D. L., & Krych, A. J. (2017). Patellofemoral arthritis after lateral patellar dislocation: a matched population-based analysis. The American journal of sports medicine, 45(5), 1012-1017. Assessment of Musculoskeletal System Essay
