Health Assessment Essay

, ,

Health Assessment Essay

Here is my assignment, kindly follow the instructions in the attachments.

A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother. A.J. is a new patient, and this is her initial visit. Her complaint is “left leg pain.”

Vitals: Temp: 37.0 C

HR: 88

RR: 16

BP: 110/72

Height: 5’ 6.”

Weight: 70.5 kg

1. Read the rest of the case study below and then complete the blank Soap Note attached to the scenario. Use only the information provided. Health Assessment Essay.

a. Decide what is pertinent and then place the components in the correct sections of subjective and objective components

b. Use appropriate abbreviations and concise terminology if appropriate

2. Provide a second Word document answering the following questions

a. What type of history will you obtain for this visit?

b. What additional history would you obtain from the family that is significant to A.J.’s situation

c. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided

d. For each of the following

i. Medical Diagnosis, 2 primary

1. Provide pathophysiology/Rationale/Plan

2. ICD 10 code

ii. Differential diagnosis, 3-5 Differentials

1. Provide pathophysiology/Rationale/plan

2. ICD 10 code

iii. Health maintenance/risk profile

iv. Pertinent positives

v. Pertinent negatives

e. Reference list

f. APA format

A.J. is a 15-year-old female, student. A.J. participates competitively in Gymnastics. She recently (3 days ago) had an injury to her left leg when she landed in an awkward position with a dismount from the uneven bars. She has previously had an injury to her left knee, so the family put a brace on and started crutch use, but has not sought medical care. The family knew that they had this upcoming appointment, so they chose to wait to seek care. The left leg pain is isolated to the front lateral aspect of the left knee; It is not improved with their interventions, the mother states that she has given A.J. Motrin 600 mg 3-4 times a day since the injury. The injury is painful at night and worse when she is up at night with pain. A.J. states that she is having trouble bending her knee when the brace is off. She is frustrated with the injury and wants it better so that she can go back to practice; she has an important meet in 2 weeks. Health Assessment Essay. A.J is currently a freshman in school (has just started back to school), previously her grades are A’s and B’s and struggles a bit in her algebra class but has utilized a tutor for help and is making progress in that class.

ORDER A PLAGIARISM -FREE PAPER NOW

A.J. states that most of her friends are in the gym, she has a few friends at school, but since the gym takes so much of her time, it is hard to have time for friends in other settings. A lot of her friends from middle school do not seem to have similar interests, 9th grade was a new school for her and mom is hinting that it has been a hard transition. Including this injury is making it hard for her to get around the campus between classes.

A.J. has no allergies

A.J. takes no medications

A.J. denies changes in her weight

A.J. eats a healthy diet, she has recently talked about becoming a vegetarian, no one in the family has food allergies, and they do not maintain a vegetarian diet. Mom is concerned that she is not getting enough protein. A.J. has not mentioned concerns with her weight but often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.

A.J. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs

A.J. denies sexual encounters, she likes boys, denies a boyfriend

A.J. participated in gymnastics five days a week for 1 to ½ hours a session, she likes to run as well but is recreational, no other clubs or interests

Previous left knee injury one year ago, no other broken bones to injuries

Birth history, term female, two other sibs (older) who are healthy. Parents are married, and state that they are happy and financially comfortable. She lives in a two story house, and her bedroom is upstairs, she is having challenges with navigating the steps with the crutches, one inside dog, no other animals. Denies mental health concerns, but has been sadder the last couple of days and mom states short tempered with a recent injury. No surgeries, hospitalizations or significant illness, trauma, or disabilities. +yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11; mom states that immunizations were up to date. Denies use of glasses or hearing aid, had her vision and hearing checked at PCP visit at age 11, has not sought primary care since that visit. A.J. denies eye or vision issues, denies issues with her hearing or ear pain, denies a headache, denies nasal drainage, nose bleeds, or problems with smell or taste. No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months.

A.J. Denies issues with her heart, no palpitations or chest pain, no syncope, no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool. Health Assessment Essay. No other concerns in her musculature other than her left knee.

A.J. is currently having issues sleeping relating to pain, she is sleeping in her bed and has tried to elevate her left leg, denies problems with concentration at school or any memory issues.

Family denies any previous blood transfusions or use of chronic medications.

A.J. started her periods at age 12 years and had them monthly, used pads and had a period in the past month, no concerns verbalized with length or intensity of bleeding, no birth control and has never seen a GYN.Health Assessment Essay.

A.J. does not work outside the home

Parents: Dad has a high-stress job and hyper tension, on medications, Mom is a stay at home mom, +weight issues but overall no meds and healthy. Siblings (one in college, girl, +weight issues and overall healthy), brother (senior in high school, is looking at going away to school, healthy). Mom states no mental health concerns in the family, denies diabetes, exposure to communicable diseases, no recent travel outside of the US, no smokers, no stroke, lung disease, or asthma, no blood disorders, seizures, headache. Paternal grandfather with hypertension

S/ Identifying Information: (initials, age/DOB, gender, reliability)		Family Hx:

		Personal/Social Hx:
Chief Complaint/RFE:

Hx Present Illness: (7 Variables but do not list as such)

CURRENT HEALTH
Medications:
Allergies:
Last PE & Screenings:
Immunization Status:
LMP & Birth Control (if applicable)
PMH
Illnesses & Trauma:
Hospitalizations/Surgeries:
OB Hx/Sexual Hx:
Emotional/Psy Hx:
REVIEW OF SYSTEMS
General
Nutrition
Skin/Hair/Nails
HEENT
Breasts
Respiratory
CV/peripheral vascular
GI
GU
MSK
Psych
Neuro
Lymph/Heme/Endocrine
O/ Physical Exam: T: P: R: BP: HT: WT: BMI:
General
Skin
Head
EENT
Neck
Breasts/Chest
Lungs
Heart/ perip vascular
Abdomen
Genitalia/Rectum
Lymph
MSK
Neuro
Medical Dx: (2max)	Rule Outs (only if applicable):
	Health Profile:
	age/gender/racial risks:
Pertinent Positives:(1DX)
	personal/family:
	screening needs:
Pertinent Negatives:	counseling needs:
	Immunization/chemo needs:
Differential DX:(3-5)	Alteration in Health Prevention R/T:
	Screening deficits:
	Counseling deficits:
Nursing Dx:	Immunization/chemo deficits:

I. PLAN: Do separate sections in the plan to include: Max 1-2 pages

Diagnostics:

Medications/Treatments:

Education:

Follow-up:

Referrals: Health Assessment Essay.

Prevention Plan:

5220 Advanced Health Assessment

Mixed up Subjective and Objective Data Work Sheet

A.J. is a 15-year-old female who is presenting to your primary clinic setting with her mother. A.J. is a new patient, and this is her initial visit. Her complaint is “left leg pain.”

Vitals: Temp: 37.0 C

HR: 88

RR: 16

BP: 110/72

Height: 5’ 6.”

Weight: 70.5 kg

Read the rest of the case study below and then complete the blank Soap Note attached to the scenario. Use only the information provided.
1. Decide what is pertinent and then place the components in the correct sections of subjective and objective components
2. Use appropriate abbreviations and concise terminology if appropriate
Provide a second Word document answering the following questions
1. What type of history will you obtain for this visit?
2. What additional history would you obtain from the family that is significant to A.J.’s situation
3. Practice using clinical reasoning and list possible diagnoses for A.J. based on the subjective information provided
4. For each of the following
  1. Medical Diagnosis, 2 primary
    1. Provide pathophysiology/Rationale/Plan
    2. ICD 10 code
  2. Differential diagnosis, 3-5 Differentials
    1. Provide pathophysiology/Rationale/plan
    2. ICD 10 code

Health maintenance/risk profile

Pertinent positives
Pertinent negatives

Reference list
APA format

A.J. is a 15-year-old female, student. A.J. participates competitively in Gymnastics. She recently (3 days ago) had an injury to her left leg when she landed in an awkward position with a dismount from the uneven bars. She has previously had an injury to her left knee, so the family put a brace on and started crutch use, but has not sought medical care. Health Assessment Essay. The family knew that they had this upcoming appointment, so they chose to wait to seek care. The left leg pain is isolated to the front lateral aspect of the left knee; It is not improved with their interventions, the mother states that she has given A.J. Motrin 600 mg 3-4 times a day since the injury. The injury is painful at night and worse when she is up at night with pain. A.J. states that she is having trouble bending her knee when the brace is off. She is frustrated with the injury and wants it better so that she can go back to practice; she has an important meet in 2 weeks. A.J is currently a freshman in school (has just started back to school), previously her grades are A’s and B’s and struggles a bit in her algebra class but has utilized a tutor for help and is making progress in that class.

A.J. states that most of her friends are in the gym, she has a few friends at school, but since the gym takes so much of her time, it is hard to have time for friends in other settings. A lot of her friends from middle school do not seem to have similar interests, 9^th grade was a new school for her and mom is hinting that it has been a hard transition. Including this injury is making it hard for her to get around the campus between classes.

A.J. has no allergies

A.J. takes no medications

A.J. denies changes in her weight

A.J. eats a healthy diet, she has recently talked about becoming a vegetarian, no one in the family has food allergies, and they do not maintain a vegetarian diet. Mom is concerned that she is not getting enough protein. Health Assessment Essay. A.J. has not mentioned concerns with her weight but often notes that she is taller than other gymnasts and gets frustrated that she is not as limber or agile as her other competitors.

A.J. Denies drugs, alcohol or use of illegal substance, no sports enhancing drugs

A.J. denies sexual encounters, she likes boys, denies a boyfriend

A.J. participated in gymnastics five days a week for 1 to ½ hours a session, she likes to run as well but is recreational, no other clubs or interests

Previous left knee injury one year ago, no other broken bones to injuries

Birth history, term female, two other sibs (older) who are healthy. Parents are married, and state that they are happy and financially comfortable. She lives in a two story house, and her bedroom is upstairs, she is having challenges with navigating the steps with the crutches, one inside dog, no other animals. Denies mental health concerns, but has been sadder the last couple of days and mom states short tempered with a recent injury. No surgeries, hospitalizations or significant illness, trauma, or disabilities. +yearly flu shots, and last got immunizations around age 11 and had one HPV and one Hepatitis A immunization at age 11; mom states that immunizations were up to date. Health Assessment Essay. Denies use of glasses or hearing aid, had her vision and hearing checked at PCP visit at age 11, has not sought primary care since that visit. A.J. denies eye or vision issues, denies issues with her hearing or ear pain, denies a headache, denies nasal drainage, nose bleeds, or problems with smell or taste. No sore throat or voice changes, no mouth or teeth issues, and routinely sees a dentist, last visit in the past six months.

A.J. Denies issues with her heart, no palpitations or chest pain, no syncope, no abdominal pain or problems with voiding or stooling, denies constipation or diarrhea and no blood in her stool. No other concerns in her musculature other than her left knee.

A.J. is currently having issues sleeping relating to pain, she is sleeping in her bed and has tried to elevate her left leg, denies problems with concentration at school or any memory issues.

Family denies any previous blood transfusions or use of chronic medications.Health Assessment Essay.

A.J. does not work outside the home

The concept with permission granted and appreciation per Dr. J Michaels.

S/ Identifying Information: (initials, age/DOB, gender, reliability)		Family Hx:
A.J. is a 15 year-old female athlete active in competitive Gymnastics. She was born in 2005. She is reliable as a historian since she is alert and of sound mind.		A.J. is the last born in a family of five. The parents are married and financially stable. Her older two siblings have no health problems. The girl is in college and overweight while the boy is in senior high school with a BMI below 25 kg/m². The family lives in a two storey house and the family keeps one pet dog inside the house. The father is hypertensive on medications. The mother who is a housewife is overweight but has no lifestyle diseases (yet). Her paternal grandfather is hypertensive too.
		Personal/Social Hx:
Chief Complaint/RFE:		A.J. is a 9^th grader who was born at term with no delivery complications. She is a freshman at the moment and admits struggling with algebra. She has many friends in the gym but few at school. She denies drug or substance use. She denies ever having sex and also denies having a boyfriend. She admits running as a hobby but denies any other interests. She practices Gymnastics for five days in a week. She denies taking alcohol or smoking. She also denies any recent travel outside the United States. She denies any concentration problems in school.
A.J. complains of pain in the left leg (“left leg pain”) on the frontolateral aspect of the knee. The pain started after she fell while practicing Gymnastics. Health Assessment Essay.
Hx Present Illness: (7 Variables but do not list as such)
A.J. is a 15 year-old female who comes to be seen with a complaint f left leg pain around the left knee on the frontolateral aspect. The pain started three days ago after falling and sustaining an injury while doing Gymnastics. The pain is sharp and keeps her awake at night. It is associated with difficulty to climb stairs and also flexion. The timing of the pain is at night after she has finished the day’s school activities. The pain is relieved by bracing and exacerbated by being awake at night. A.J. has not rated her pain on a scale of 1-10.
CURRENT HEALTH
Medications: A.J. is taking OTC Motrin 600 mg three to four times a day. She denies taking any other medications.
Allergies: She denies any allergies to food or medicine. She also denies having allergic conditions like eczema or asthma.
Last PE & Screenings: Her last Primary Care Physician visit was at the age of 11 years. She was checked for vision and hearing. She denies use of hearing aids or eye glasses. She was also checked by a dentist six months ago. She denies any problems with her teeth and mouth. She denies undergoing screening of any nature. Health Assessment Essay.
Immunization Status: All childhood immunizations were up to date. She last got immunized at the age of 11 years when she got the Human Papilloma Virus (HPV) and Hepatitis A vaccinations. She still gets yearly flu vaccinations.
LMP & Birth Control (if applicable) Her menarche was at the age of 12 years. Her menstrual flow is regular and she denies any problems with the length and intensity of bleeding. Her LMP was in August. She denies any contraceptive use.
PMH
Illnesses & Trauma: A.J. denies any previous illnesses. But she admits a left knee injury one year ago.
Hospitalizations/Surgeries: She denies any previous hospitalizations or surgeries.
OB Hx/Sexual Hx: She denies being sexually active and also denies having a boyfriend. She has therefore never been pregnant and is para 0+0. She does not use any form of birth control and denies ever seeing a gynecologist.
Emotional/Psychological Hx: She denies any mental health condition. Also denies having concentration problems at school. Mother admits A.J.’s recent emotional lability after the leg injury.
REVIEW OF SYSTEMS
General No weight loss, weakness, fatigue, chills, or fever.
Nutrition She takes a healthy diet full of vegetables. Admits planning to become a vegetarian.Health Assessment Essay. Her BMI shows that she is borderline overweight at 25.1 kg/m².
Skin/Hair/Nails No lice, no rashes, no itching.
HEENT No blurred or double vision, no visual loss. No tinnitus, no hearing loss, no earache. No rhinorrhea, no nasal congestion, no sneezing, and no sore throat.
Breasts Denies swellings or masses. Denies cracked nipples or discharge.
Respiratory No wheezing, no coughing, no phlegm, no orthopnea, no hemoptysis, and no shortness of breath.
CV/peripheral vascular No chest pain, no palpitations, no chest pressure or discomfort, no edema. Also no paraesthesia or numbness of extremities.
GI Denies nausea, vomiting, or diarrhea. No abdominal pain, no blood in stool, and no melena.
GU No incontinence. No burning sensation on urination. Denies pregnancy. Last menstrual period last month.
MSK Pain on the left knee with stiffness and a limitation in the range of movements.
Psych Denies history of psychosis, depression, or anxiety. Health Assessment Essay.
Neuro Denies syncope or hemiparesis.
Lymph/Heme/Endocrine Denies swollen glands (enlarged nodes). Denies splenectomy.
O/ Physical Exam: T: 37.0°C P: 88 b/m R: 16 br/m BP: 110/72 mmHg HT: 5’ 6” WT: 70.5 kg BMI: 25.1 kg/m²
General She is alert and oriented in space, time, place, and person. She is well nourished and her mucous membranes are moist. Her BMI shows that she is borderline overweight (25.1 kg/m²). She has no fever.
Skin Good skin turgor and elasticity. No rashes or eczema. No bruises.
Head Normocephalic and atraumatic.
EENT Both pupils equal, round, and reactive to light and accommodation. No discoloration of the sclerae. Intact extraocular muscles. Ears symmetrical with no discharge. Intact tympanic membranes. Nostrils symmetrical with no nasal polyps. Throat shows no exudate.
Neck Demonstrates a good range of motion with no obvious nuchal rigidity. No lymphadenopathy.
Breasts/Chest No masses on palpation. Nipples not cracked. No visible discharge. No chest indrawing.
Lungs No increase in breath sounds, no dullness to percussion, no crackles, no wheezes, no rhonchi, no rales, no crepitations, and no rubs.
Heart/ Peripheral vascular No murmurs, no rubs, no gallops. Heart sounds S1 and S2 present. Rate and rhythm regular. Peripheral capillary refill present and fast. No cyanosis, clubbing, or edema.
Abdomen The abdomen is soft, non-tender, and not distended. No rebound tenderness or guarding. No hepatosplenomegally or other masses on palpation. Health Assessment Essay. Bowel sounds are present.
Genitalia/Rectum Pubic hair present. No ulcers or warts. No PV discharge. No haemorrhoids on rectal examination.
Lymph No nodes palpable. No lymphadenopathy.
MSK Pain, heat, tenderness, swelling, and a limited range of movement on the left knee. There is guarding on palpation of the same knee.
Neuro All the twelve cranial nerves are intact. No aphasia and no hemiparesis.
Medical Dx: (2 max) 1. A torn meniscus (Motion Medical Center, n.d.). 2. Anterior cruciate ligament (ACL) injury	Rule Outs (only if applicable):
	Health Profile: A.J. is a healthy teenager. Chances of having degenerative disease are small.
	Age/gender/racial risks: It is unlikely that A.J. is suffering from arthritis because she is young. A small chance exists though because of overuse of the knee joint since she is an athlete.
Pertinent Positives:(1DX) · Pain, swelling, heat, and tenderness of the left knee · A limited range of movement (reduced mobility) with difficult flexion and extension
	personal/family: N/A
	screening needs: N/A
Pertinent Negatives: · Lack of inability to move the left limb · Lack of palmar erythema, erythema nodosum, and/ or scleritis.	counseling needs: Counselling cannot be ruled out as A.J. appears to be undergoing a nervous breakdown because she cannot participate in Gymnastics as she would like due to the knee pain.
	Immunization/chemo needs: N/A
Differential DX:(3-5) 1. Patellofemoral joint injury 2. A patellar fracture (OrthoInfo, 2017). 3. A dislocated kneecap or patellar dislocation (Gemas, 2015). Health Assessment Essay.	Alteration in Health Prevention R/T:
	Screening deficits: N/A
	Counseling deficits: N/A
Nursing Dx: Sleep deprivation due to chronic pain related to trauma on the left knee.	Immunization/chemo deficits: N/A

I. PLAN: Do separate sections in the plan to include: Max 1-2 pages

Diagnostics:

A.J. will require diagnostic imaging tests to be done. A plain X-ray with antero-posterior and lateral views will be able to show any meniscus rupture, patella dislocation, or any fracture. This in itself would be confirmatory for the diagnosis. A computerized tomography (CT) scan will be even better at demonstrating any structural damage to the knee joint. This includes any rupture of the ligaments such as the anterior cruciate ligament (ACL). Yet another imaging test that can provide better diagnostic confirmation is magnetic resonance imaging or MRI. It will provide visual diagnostic information akin to the one provided by CT scan, in real time. Lastly is an ultrasonic (US) scan. This one will enable the imaging of any part of the knee joint in real time by simply moving the transducer to the location wanted (for instance over specific ligaments).

Medications/Treatments:

Treatment will assume that the diagnosis is the most likely one presented above – a torn meniscus (Motion Medical Center, n.d.). Treatment can be conservative or surgical, but the former is preferred for small tears that can heal with treatment. This conservative treatment can be (i) use of stem cell injections to spur regeneration of the tissues and speed up the natural healing process, and/ or (ii) cold laser therapy in ten-minute sessions. Laser therapy helps reduce the pain as well as the swelling (Motion Medical Center, n.d.). Pain relief will be achieved by anti-inflammatory agents such as Ibuprofen 500 mg to 1 g three times a day (Katzung, 2018).Health Assessment Essay. If conservative medical treatment fails or the tear is too extensive to be repaired, then surgical meniscectomy will be carried out through referral to an orthopedic surgeon.

Education:

Education to patient A.J. will focus on safety during training and the importance of using a cold press immediately after such traumatic injury.

Follow-up:

A.J. will require follow up after the initial treatment. This will be to monitor the healing process and the progress with rehabilitation back to full functionality. This can be done on a weekly basis until full range of motion is restored.

Referrals:

Referral will be to the physiotherapist for rehabilitation.

Prevention Plan:

The prevention plan will involve educating the mother on the importance of buying for A.J. protective gear such as knee caps for use during training.

II. Rationale: ( Max 2 pages)

The rationale for the above plan is based on the fact that a meniscus tear is the most likely diagnosis as per the available evidence. Available statistics show that meniscal injures of the knee have an incidence of 61 cases in every 100,000 persons. The prevalence ranges between 12% and 14%. There are about 850,000 cases of injury to the menisci in the United States annually. Additionally, repair of torn menisci accounts for about 10% to 20% of all orthopedic surgeries. Women experience the highest peak incidence of meniscal tears between the ages of 11 years and 19 years, which is the age group of A.J. (Pekkerman et al., 2017).

Because A.J. is a Gymnast, she frequently places her weight on one leg and also makes sudden twisting and rotating movements. These are the most common reasons for traumatic meniscal tears (Motion Medical Center, n.d.). A.J. is also experiencing extreme pain and a limitation in movement or stiffness with the injured knee. The pain is so much that she cannot sleep well at night. This is the classic presentation of a torn meniscus, according to the Motion Medical Center (n.d.).

III. Patho: (Max 2 pages)

The menisci are C-shaped (or crescent-shaped) cartilaginous structures located in the knee joint. Their function is to provide a cushioning effect when weight is placed on the leg. They are primarily avascular but receive blood supply to some extent fro branches of the popliteal artery.Health Assessment Essay. In young patients, meniscal tears usually have occurred as a result of sports activities such as in the case of A.J. the injury or tear typically occurs when an athlete makes a twisting or shearing motion on a flexed knee. There is the medial and the lateral menisci and the tears can be categorized as being horizontal, vertical, radial, oblique, or complex (Pekkerman et al., 2017).

References

Gemas, T. (September 28, 2015). Symptoms of kneecap dislocation. Sports-health. https://www.sports-health.com/sports-injuries/knee-injuries/symptoms-kneecap-dislocation

Katzung, B.G. (Ed.) (2018). Basic and clinical pharmacology (14^th ed.). McGraw-Hill Education

Motion Medical Center (n.d.). Meniscus tears can be very painful. Here’s what to know. https://www.motionspinesport.com/meniscus-tears-can-be-very-painful-heres-what-to-know/

OrthoInfo (2017). Patellar (kneecap) fractures. https://orthoinfo.aaos.org/en/diseases–conditions/patellar-kneecap-fractures/

Pekkerman, B., Ralhan, P., & Chang, R.G. (August 7, 2017). Meniscus injuries of the knee. https://now.aapmr.org/meniscus-injuries-of-the-knee/#diseasedisorder

Additional History and Diagnosis: The Case Study of A.J.

Type of History

The type of history the author would obtain for this visit by 15 year-old A.J. and her mother would be the girl’s sports history, history of trauma, and past surgical history. Her sports history will reveal whether she has been having repeated injuries, a fact that would indicate usage of improper technique as a gymnast or lack of safety/ first aid measures in training. A positive history of trauma would point to the possibility that the knee injury is a repeated event. This would mean that the knee could be degenerating at a fast rate. Lastly but not least, past surgical history may shed some light on the possibility of already having undergone surgery for a similar injury. .Health Assessment Essay

Additional History

The most important additional history that needs to be obtained from the family and that is significant in the case of A.J. is the emergency treatment that she received immediately after the injury occurred in the gym. This history will be important in order to understand the progression of the injury and to plan future treatment and rehabilitation.

Two Possible Primary Diagnoses for A.J.

Torn meniscus (Motion Medical Center, n.d.)

The pathophysiology of this diagnosis is that the medial or lateral meniscus gets torn as a result of a sudden shearing, rotating, or twisting motion as occurs in sporting activities. The ease of this injury is explained by the fact that these crescent-shaped structures are cartilaginous in nature. The plan is to perform diagnostic imaging such as MRI to confirm the diagnosis, then to treat conservatively or perform surgery if the former fails. The ICD-10-CM code for this diagnosis is S83.2.

ORDER A PLAGIARISM -FREE PAPER NOW

Anterior cruciate ligament (ACL) injury

This injury to the knee occurs during individual sporting manoeuvres without contact in about 70% of cases. It happens when an athlete tries to quickly change direction while pivoting. The plan is for imaging studies to confirm diagnosis followed by conservative management or surgical repair. The ICD-10-CM code for this diagnosis is S83.512A.

Three Possible Differential Diagnoses for A.J.

Patellofemoral injury: This one occurs when there is traumatic contact of the posterior surface of the patella with the femur. The plan is to conservatively treat the injury and relieve the pain. The ICD-10-CM code is M22.2X2.
Patellar fracture (OrthoInfo, 2017): This one occurs when compressive forces cause fracture to the patellar bone of the knee such as a comminuted fracture. The rationale is that the energy in the traumatic blow is absorbed by the kneecap. The plan is either conservative management of surgical repair. The ICD-10-CM code is S82.002A.

Dislocation of the patellar: The quadriceps muscle pulls the patellar bone in a lateral direction causing instability and trauma as may occur during sporting activities, with resulting patellar dislocation. The plan is to manage the injury conservatively. The ICD-10-CM code is S83.095A.

Health Maintenance/ Risk Profile, Pertinent Positives and Pertinent Negatives

The risk profile for patient A.J. is significantly high because she is an athlete and is in the age group of 11-19 years. This is the age range for girls in which meniscal tears are at their peak (Pekkerman et al., 2017). The pertinent positives are (i) pain, swelling, heat, and tenderness of the left knee, and (ii) reduced mobility with difficult flexion and extension. The pertinent negatives are (i) lack of inability to move the left limb, and (ii) lack of palmar erythema, erythema nodosum, and/ or scleritis. Health Assessment Essay.