Response to Brooke Menefee Post on Ankle Pain Case Study

The patient in your case study is a 46 year-old African American female who is still fit to play soccer even at her age. She presents with a traumatic ankle injury manifested by ankle pain for the previous three days. It is notable that the patient still plays recreational soccer and is active through daily exercise. Because of this, the possibility of wear and tear injuries cannot be ruled out. You did tests and other diagnostics and combined the information from the results with the other subjective and objective information retrieved from the history and physical examination (Ball et al., 2019; Bickley, 2017). Your differential diagnoses – presumably in order of likelihood – were as follows:

• Acute ankle pain
• Ankle injury, soft tissue
• Ankle fracture
• Calcaneous fracture
• Ruptured tendon
• Osteoarthritis (bilateral)

An analysis of the conditions you have diagnosed shows that the first two differentials are at best ambiguous and non-specific. They generically refer to ‘pain’ and ‘soft tissue injury’ without providing specific details that would help with the therapeutics. I would therefore reject both. The third and fourth differentials are more specific and refer to fractures in the ankles. These I would reject outright too because the patent stated clearly that they can bear weight. It is clinically fallacious to believe that a patient with a fracture of the ankle would still be able to bear weight. Response to Brooke Menefee Post on Ankle Pain Case Study. The fifth and sixth differential diagnoses are the ones that are probable given the patent’s history and physical examination findings. It is possible that she had tendon rapture during the soccer game. It is also very likely that the lady is suffering from OA. However, I would still reject these as the primary diagnosis in favor of a simple diagnosis of Ankle Sprain (Schick, 2019). This is because the lady can still bear weight, which means that there is still structural integrity of the ankle joints bilaterally. My only other differential diagnosis would then be osteoarthritis or OA.

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References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Schick, F.A. (February 5, 2019). Five of the most common foot and ankle injuries. https://rothmanortho.com/stories/blog/Common-Foot-And-Ankle-Injuries

Assessing Musculoskeletal Pain: Response to Lisley Miller on the Post on Back Pain

Your case analysis of the case study of the 42 year-old male patient presenting with lower back pain is quite comprehensive. It has followed the episodic SOAP note notation as it is supposed to be. Your patient presents with lower back pain for the past one month. He also states that his pain radiates to his left leg. You have done subjective evaluation of the patient in the form of the chief complaint, the history of presenting illness, current medications, allergies, past medical history, social and family history, and the review of systems (Ball et al., 2019). However, it is in your objective assessment that you have performed tests and manoeuvers that are aimed at coming up with the correct diagnosis for the patient. Response to Brooke Menefee Post on Ankle Pain Case Study. It is clear that you focused more on the musculoskeletal system and the neurological system. From your narration, you gave prominence to physical examination and stated that diagnostics are not necessary in this case. I agree with you about the statement that diagnostics may not be necessary. However, I wish to point out that this statement must be qualified by another statement that states that the physical examination in this case must not leave anything to chance. Te nerves supplying the skeletal muscles of the lower limbs must be assessed, as well as the muscles themselves.

You note that you checked for the presence of the so-called “red flags”. I agree with you on that. Clinical red flags can be helpful in coming up with the correct diagnosis and ruing out others that were promising but misleading. Some of the red flags that you have checked for include progressive sensory and motor loss, urinary retention and bladder incontinence, and a history of cancer or trauma. During the physical examination, you performed the Faber test to rule out the possibility of a sacroiliac origin of the pain. You also performed fist percussion over the costovertebral angles. From your narration, the rationale for this was to differentiate flank pain caused by kidney disease from pain coming from spinal injury. The differential diagnoses that you came up with after your subjective and objective evaluation that was devoid of diagnostics were:

1. Lumbosacral radiculopathy
2. Lumbosacral muscle strain

• Lumbar spondylosis

1. Compression fracture, and
2. Spondylosis

From my own point of view, I would reject all of these diagnoses because they do not conform entirely to the symptomatology presented by the 42 year-old patient. The other reason for the rejection of these diagnoses is that they do not correspond to sound clinical reasoning that should have taken place before arriving at the differential diagnoses. No proper justification or rationale has also been given for the decision to include these specific differential diagnoses.

According to my assessment, therefore, the most likely musculoskeletal condition that this 42 year-old patient could be suffering from is Acute Back Pain with Sciatica (Fritz et al., 2020; Hall et al., 2019). It is notable that this diagnosis does not appear among the ones that you came up with, even though ‘lumbosacral radiculopathy’ comes close. However, according to this patient’s presentation; this is the most likely primary diagnosis. Sciatica frequently accompanies cases of lower back pain that radiates to the legs. The most common cause is usually compression of one or more of the lumbar discs (Fritz et al., 2020; Hall et al., 2019). According to Hall et al. (2019), sciatica is also referred to as nerve root pain or lumbar spinal radiculopathy. It is one way that lower back pain (LBP) manifests and is defined by pain that frequently radiates to the leg and sometimes into the foot and toes . Response to Brooke Menefee Post on Ankle Pain Case Study.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Fritz, J.M., Lane, E., McFadden, M., Brennan, G., Magel, J.S., Thackeray, A., Minick, K., Meier, W., & Greene, T. (2020). Physical therapy referral from primary care for acute back pain with sciatica: A randomized controlled trial. Annals of Internal Medicine, 1-11. https://doi.org/10.7326/M20-4187

Hall, J.A., Konstantinou, K., Lewis, M., Oppong, R., Ogollah, R., & Jowett, S. (2019). Systematic review of decision analytic modelling in economic evaluations of low back pain and sciatica. Applied Health Economics and Health Policy, 17, 467-491. https://doi.org/10.1007/s40258-019-00471-w

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.

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?

CC: Lower back pain

HPI:  Pt is a 42-year old male who presents with complaints of lower back pain for the past month that sometimes radiates to his left leg. Additional information that would be helpful to determine the cause of pains include characteristics of pain: severity, constant, relationship to specific position or change in position. The history should also include information about aggravating or relieving factors, associated symptoms (fever, headaches, dizziness, nausea, vomiting, etc.), and any treatment he has tried.

Current Medications: Additional information would be helping in determining cause of pain includes if there is use of corticosteroids or immune-suppressing medications. It would also be beneficial to have information about the use of NSAIDs, calcium supplements, glucosamine.

Allergies: This section should include medication, food, and environmental allergies.

PMHx: This section should include information about any history of musculoskeletal problems or surgery or  any recent trauma.

Soc Hx: It would be helpful to have information about potential occupational hazards, tobacco or alcohol use, illicit drug use (especially IV). Information related to risk factors of obesity and low physical activity should be included because obesity and low levels of physical activity independently increase the risk of radiating low back pain  (Shiri, et al., 2013).

Fam Hx: This section should include information about any family history of musculoskeletal disorders or cancer. Response to Brooke Menefee Post on Ankle Pain Case Study.

ROS:

GENERAL:  This section should include information about activity changes, chills, diaphoresis, and fever. The presence of a fever indicates an inflammatory condition such as spondyloarthropathy or systemic infection, Ewing sarcoma, vertebral osteomyelitis or discitis (Dains, Baumann, & Sheibel, 2019).

SKIN:  This section should include information about the presence of any localized bruising or erythema, as well as the presence of a rash or itching.

CARDIOVASCULAR:  This section should include information about any noted chest pain, palpitations, or edema.

RESPIRATORY:  This section should include information about any noted for cough, shortness of breath or wheezing.

GASTROINTESTINAL: This section should include information about abdominal pain, blood in stool, constipation, diarrhea, nausea, and vomiting.

GENITOURINARY:  This section should include information about any changes in urinary status including urinary retention or incontinence. Should include information about symptoms related to pyelonephritis.

NEUROLOGICAL:  This section should include information about weakness, dizziness, numbness, and headaches. Should include information about numbness and tingling in extremities, as well as  change in bowel or bladder control.

MUSCULOSKELETAL:  Positive for low back pain which sometimes radiates to his left leg. This section should include information about any changes or limitations in ROM, and if the pain affects ADLs/ IADLs.

PSYCHIATRIC:  Additional information to include: Is the patient nervous or anxious? Is there a history of depression or anxiety. How is the pain affecting his mood and psychological well-being?

O.

Physical exam: A thorough exam including cardiovascular, respiratory, abdominal, genitourinary, musculoskeletal, neurologic, and skin assessment should be performed in all cases of low back pain with a  focus on the musculoskeletal and neurological systems. In patients with radicular pain, the physical exam should focus on the lumbar 4 and 5 and sacral 1 (L4, L5 and S1) nerve roots because nerve impingement commonly occurs at these areas of the spine, and in most instances, if the physical exam is comprehensive, diagnostics are not necessary (Pfieffer, 2019). Examiner should note presence of red flags: progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age, as these indicate non-mechanical pain which requires prompt further evaluation and imaging (Will, Bury, & Miller, 2018).

GENERAL: Awake, alert, and oriented x3. In no apparent distress

SKIN: This section should include information about skin temperature and color, and any rashes, lesions, or abrasions.

CARDIOVASCULAR: This section should include information re rate, rhythm, normal S1, S2, murmurs, rubs, clicks or gallops.

RESPIRATORY: This section should include information about respiratory effort as well as normal/abnormal breath sounds.

GASTROINTESTINAL: An abdominal exam should also be performed to determine if visceral pain is radiating to the back. This is best done with the psoas assessment, which involves internal and external hip flexion (Pfieffer, 2019).Response to Brooke Menefee Post on Ankle Pain Case Study.  The abdominal exam should also include palpation of abdominal organs and auscultating for bowel sounds and bruits.

GENITOURINARY: This section should contain information about bladder palpation and percussion, any flank discomfort and any symptoms related to urinary retention or pyelonephritis.

MUSCULOSKELETAL: During the physical exam, I would palpate and percuss the patient’s back to determine if tenderness is in the paravertebral muscular or midline spinous processes;  perform FABER test to rule out the sacroiliac joint as site of origin; and  perform fist percussion over the costovertebral angles  and spine to discriminate flank pain caused by renal disease from spinal pathology, as well as to localize tenderness. (Dains, Baumann, & Sheibel, 2019). The physical examine would include the straight leg raise test, which is sensitive and specific to disk herniation and would be performed to assess for L4, L5 and S1 nerve involvement (Pfieffer, 2019). The physical exam should check for equal extension and flexion at the knees, as well as bilateral dorsiflexion and plantar flexion.

• BACK: Should include any information about ROM and tenderness.
• EXTREMITIES: Focused to bilateral lower extremities. The physical exam should check for equal extension and flexion at the knees, as well as bilateral dorsiflexion and plantar flexion. Exam should include information about clubbing, cyanosis, or edema

NEUROLOGICAL: Physical examination should check to see if Cranial nerves 2-12 are intact and if there are  any focal deficits. Should assess for normal gait and station. Should assess muscle strength on a scale of 0/5 to 5/5. Should assess for distal sensation.

HEMATOLOGIC: This section should include information about any peripheral edema, capillary refill and peripheral pulses. The exam should include assessing for any bruising or discoloration over spine.

Diagnostic results: Lab and diagnostic tests are not performed initially for patients with acute back pain unless the NP suspects any of the red flag symptoms (Pfieffer, 2019). The American Society of Anesthesiologists, American College of Family Physicians, American Academy of Family Physicians and American College of Physicians, and North American Spine Society have recommendations re limiting the use of imaging studies for acute back pain, especially in the absence of red flags, traumatic injuries, and within the first six weeks in patients with non-specific acute back pain (Will, Bury, & Miller, 2018). If indicated, the first diagnostic test to be considered should be a plain radiologic film of the spine. Response to Brooke Menefee Post on Ankle Pain Case Study. Plains films are less costly and there is little difference in patient outcomes when comparing patients who had plain films to those who received more-costly CT or MRI imaging  (Pfieffer, 2019). An x-ray would be beneficial for mechanical problems such as fracture, while a CT or MRI would be more useful beneficial in diagnosing a herniated disk or with concerns re a neurological problem.

A.

Differential Diagnoses 

1. Radiculopathy, Lumbosacral
2. Lumbosacral muscle strain
3. Lumbar Spondylosis
4. Compression Fracture
5. Spondylosis

Low back pain can have structural causes (neurogenic causes, or extraspinal causes (including relating to visceral organs)  (Amirdelfan, McRoberts, & Deer, 2014). Low back pain is usually non-specific or mechanic (arising intrinsically from the spine, intervertebral disks, or surrounding soft tissues; and includes lumbosacral muscle strain, disk herniation, lumbar spondylosis, spondylolisthesis, spondylolysis, vertebral compression fractures, and acute or chronic traumatic injury  (Will, Bury, & Miller, 2018).

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Amirdelfan, K., McRoberts, P., & Deer, T. R. (2014). The differential diagnosis of low back pain: a primer on the evolving paradigm. Neuromodulation : Journal of the International Neuromodulation Society, 17 Suppl 2, 11-17. https://doi-org.ezp.waldenulibrary.org/10.1111/ner.12173

Dains, J., Baumann, L., & Sheibel, P. (2019). Advanced Health Assessment and Clinical Diagnosis in Primary Care (Vol. 6th ed.). St. Louis, MO: Elsevier Mosby.

Pfieffer, M. L. (2019). Evaluating and managing low back pain in primary care. Nurse Practitioner, 44(8), 40-47.https://doi-org.ezp.waldenulibrary.org/10.1097/01.NPR.0000574664.42110.77

Shiri, R., Solovieva, S., Husgafvel, P. K., Telama, R., Yang, X., Viikari, J., . . . Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis and Rheumatism, 42(6), 640-650. doi:10.1016/j.semiarthrit.2012.09.002

Will, J. S., Bury, D. C., & Miller, J. A. (2018). Mechanical Low Back Pain. American Family Physician, 98(7), 421-428. https://www.aafp.org/afp/2018/1001/p421.html

Assessing Musculoskeletal Pain in a 15 Year-Old Male Presenting with Dull Pain in Both Knees: An Episodic SOAP Note

Patient Information

Initials: CK     Age: 15 years              Sex: Male        Race: Caucasian

SUBJECTIVE

CC: Patient CK presents with a complaint of dull knee pain bilaterally. He states that the knees click at times, producing what he describes as a “catching sensation” under the kneecap or patella.  

History of Presenting Illness (HPI): The HPI is negative for previous history of such knee pain as described by patient CK. The onset of the pain was five days ago and the patient does not report suffering any injury such as in a sporting activity. The pain is located on both knees behind the patella. Response to Brooke Menefee Post on Ankle Pain Case Study.  It is intermittent pain that comes on and off and lasts for a period of approximately three minutes at a time. The pain is characterized by dullness and a pulling sensation behind the kneecaps bilaterally. It is aggravated by walking and mitigated or relieved acetaminophen as an OTC prescription. The knee pain is more frequent and intense during the day when patient CK is active. He currently rates its severity at 7/10.

Current Medications:

1. Acetaminophen 1 g orally TDS (OTC)
2. Ortho topical knee spray to be applied TDS (OTC)

Allergies: Negative for allergies to medications, foods, and environmental irritants like dust, smoke, or pollen.

Past Medical/ Surgical History

1. Admission in 2010 for sepsis
2. Left inguinal herniorraphy in 2016

Social History: The patient stays with his family of mother, father, and a younger sibling who is a sister aged six years. They live in a wealthy neighborhood with access to all necessary amenities one would need. He has been brought up to know that a seatbelt must be worn at all times in the car and that driving while talking on the phone is dangerous and illegal. His father drinks occasionally over the weekends but does not smoke. His mother neither smokes nor takes etoh. The patient himself denies etoh or smoking.

Family History: Family history for patient CK is positive for hypertension in the father, obesity and type II diabetes in the mother, and cardiovascular disease in the maternal grandmother. The paternal grandfather died of a heart attack (myocardial infarction).

Review of Systems, ROS

General: This is negative for fatigue, malaise, recent weight loss, weakness, chills, or fever.

HEENT: Negative for headaches, diplopia, tearing, or blurred vision. Also negative for otorrhea, tinnitus, and earache. Denies sneezing and rhinorrhea. Negative for sore throat or dysphagia.

Integumentary (Skin): Negative for itching, rashes, or allergic skin conditions.

Gastrointestinal: Negative for constipation, diarrhea, vomiting, hematemesis, and nausea. Reports regular unchanged bowel movements. Latest bowel movements reported to be at home the morning of the hospital visit. Response to Brooke Menefee Post on Ankle Pain Case Study.

Cardiovascular: Negative for palpitations, chest pain or chest tightness. Denies fainting or having cold/ pale extremities.

Respiratory: Negative for dyspnea, coughing, hemoptysis, or pedal edema.

Genitourinary: Negative for dysuria, frequency of micturition, cloudiness of urine, or anuria. Reports being heterosexual and attracted to the opposite sex.

Neurological: Negative for loss of bladder and bowel control. Denies paraesthesia in the extremities as well as any loss of consciousness.

Musculoskeletal: Patient CK reports bilateral dull knee pain that occasionally produces a catching sensation. Positive for joint stiffness and a limited range of motion on both knee joints. Negative for back pain or myalgia.

Endocrinologic: Negative for polyuria and polyphagia. He denies excessive diaphoresis as well as heat intolerance. He also denies treatment with hormonal therapy.

Lymphatics: Negative for lymphadenopathy and splenectomy.

Hematologic: Negative for blood and clotting disorders. He denies dizziness, hematochezia, or melena.

Psychiatric: Negative for depression and anxiety. He denies receiving any psychiatric diagnosis or therapy.

Allergic/ Immunologic: Negative for food, drug, and environmental allergies. Denies immunosuppression of whatever cause, including HIV.

OBJECTIVE

General/ Constitutional: The patient is well-groomed and appropriately dressed for the weather and time of the day. He has no abnormalities in gait and speech. He is alert and oriented in time, place, space, person, and event. V/S T: 98.8°F; BP: 110/70 mmHg; RR: 14/ min; P: 68 b/m.

HEENT: On inspection, the head is normocephalic and atraumatic. PERRLA. EOMI. Clear sclerae bilaterally with no discoloration. Negative for otorrhea or perforated tympanic membranes bilaterally. No fluid levels in both ears. Nasal septum centrally placed. The nasal turbinates are not inflamed. No evidence of rhinorrhea or nasal polyps. The throat is not erythematous and there is no exudate.

Cardiovascular: S1 and S2 heard, regular in rate and rhythm. No bruits.

Respiratory: Lung fields are clear bilaterally. No rales, crepitations, rhonchi, or wheezing. No use of accessory muscles of respiration.

Musculoskeletal System: Inspection: The knee joints appear rigid. Palpation: Tenderness and guarding of the knee joint bilaterally. Limited range of motion in both knees. No crepitus or evidence of effusion into the knee joint. The Q-angle or quadriceps angle (Emami et al., 2007) is approximately 18% on measurement (a risk of knee injuries). Response to Brooke Menefee Post on Ankle Pain Case Study. Anterior drawer test negative but patellar apprehension test positive (Ball et al., 2019; Bunt et al., 2018; Bickley, 2017).

Diagnostic tests:

1. Radiologic examination: Bilateral knee X-rays.
2. Patellar apprehension test (Bunt et al., 2018): Tests for lateral patellar instability. There is anxiety and resistance when forced lateral displacement is applied to the patella.
3. McMurrays test (Bunt et al., 2018): Tests for the presence of a meniscal tear in the knee joint.
4. Ballottement test or patella tap test (Bunt et al., 2018): This determines if there is presence of effusion in the knee joint.
5. Lachman test (Bunt et al., 2018): It assesses the integrity of the anterior cruciate ligament or ACL. A positive test shows ACL instability.
6. Anterior drawer test (Bunt et al., 2018): Also tests for injury to the ACL.
7. Pivot shift test (Bunt et al., 2018): Tests for injury to the ACL.
8. Thessaly test (Bunt et al., 2018): It tests for the presence of meniscal tears
9. Laboratory tests: Rheumatoid factor test for rheumatoid arthritis (Bunt et al., 2018; Hammer & McPhee, 2018).

The results show a positive patellar apprehension test but the rest of the tests were either inconclusive (equivocal) or negative. This indicated that patient CK had no fracture or injury to the menisci, anterior cruciate ligament, or the patellar bone itself.

Assessment

According to the subjective and objective information above, the most likely primary diagnosis for patient CK is lateral subluxation of the patella. The best rationale for this is that the patellar apprehension test was positive. The Q angle was also quite high, predisposing the patient to subluxation when the quadriceps muscle pulls the patellar during movement (Bunt et al., 2015; Gemas, 2015). The other differential diagnoses are:

1. Collateral ligament sprain

This is a differential diagnosis that would cause pain of lateral or medial origin. It remains a likely diagnosis for this patient (Bunt et al., 2018; Bickley, 2017).

2. Medial plica syndrome

MPS is also a possible diagnosis for patient CK because it is known to produce symptoms such as tenderness, catching and clicking as reported by the patient in the subjective portion. Tenderness is also present (Bunt et al., 2018). Response to Brooke Menefee Post on Ankle Pain Case Study.

3. Sinding- Larsen-Johannson syndrome (distal patellar apophysitis)

The condition is a possibility but not a probability. It typically affects children between 10 and 13 years old. It causes characteristic tenderness in the knee joint (Bunt et al., 2018).

4. Osgood-Schlatter disease (tibial apophysitis)

It is atraumatic and is usually marked with tenderness too. It is common in adolescents (Bunt et al., 2018), and patient CK is an adolescent.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Bunt, C.W., Jonas, C.E., & Chang, J.G. (2018). Knee pain in adults and adolescents: The initial evaluation. American Family Physician, 98(9), 576-585. https://www.aafp.org/afp/2018/1101/p576.html

Emami, M-J., Ghahramani, M-H., Abdinejad, F., & Namazi, H. (2007). Q-angle: An invaluable parameter for evaluation of anterior knee pain. Archives of Iranian Medicine, 10(1), 24-26. https://pubmed.ncbi.nlm.nih.gov/17198449/#:~:text=Background%3A%20Patellofemoral%20pain%20syndrome%20is,the%20most%20common%20knee%20problem.&text=Theoretically%2C%20a%20higher%20Q%2Dangle,patella%20and%20potentiates%20patellofemoral%20disorders

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

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education. Response to Brooke Menefee Post on Ankle Pain Case Study.

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:

C

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? Response to Brooke Menefee Post on Ankle Pain Case Study.

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.

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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.

From the professor

Welcome to Week 8. This week we will be reviewing the Musculoskeletal System. You have a discussion post this week dealing with the assessment of musculoskeletal pain. You will be assigned a case study below. Response to Brooke Menefee Post on Ankle Pain Case Study. You will post an episodic/focused note about the patient you are assigned and provide at least five different possible conditions that may be considered as a differential diagnosis. Please see assignment details for full instructions.

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?

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Response to Brooke Menefee Post on Ankle Pain Case Study