Evaluation of knee pain should begin with general questions regarding duration and rapidity of symptom onset and the mechanism of injury or aggravating symptoms
Episodic/Focused SOAP Note Template “Evaluation of knee pain should begin with general questions regarding duration and rapidity of symptom onset and the mechanism of injury or aggravating symptoms” (Papadakis & McPhee, 2019, p. 1709). Patient Information: Subjective CC “my knees hurt” HPI: TC is a 15-year-old Caucasian male who presents today complaining of bilateral knee pain, currently a 4 out of 10; however, when he runs, the pain increased to a 7 out of 10. He is unsure of when the pain started. He describes the pain as dull, and sometimes “click” with a “catching sensation” under the patella. Physical activity makes the pain worse and rest makes the pain better but does not completely resolve the pain. Additional information that would be helpful for evaluation and diagnosis: Has TC had this type of pain before? Does he have any swelling, redness or are his knees hot? Does he recall any injuries? Current Medications: One-a-Day multivitamin, daily, EpiPen PRN bee sting Allergies: Seasonal allergies, bee stings PMHx: Anaphylaxis to bee stings No other significant past medical history Additional information that would be helpful for evaluation and diagnosis: Has he had surgeries to his knees? Has he had any other traumatic injury events (i.e. motorcycle/motor vehicle accident)? Soc Hx: TC is a sophomore in high school, is excited to test for his driver’s permit next year. He lives in a residential home with parents (mom and dad), two brothers and one sister. He is a runner in his high school’s track team and works part-time at the mall three nights a week. Denies drinking alcohol and smoking cigarettes, however; he admits to smoking marijuana once or twice a month with his friends. Fam Hx: Mom – HTN, HLD, Dad – DM Type 1 Brother (SC) – 2 years younger, no significant medical history Brother (JC) – 4 year younger, no significant medical history Sister – 1 year older, asthma – diagnosed at 4 years old Maternal Grandmother – alive, 88 y/o, HLD, glaucoma Maternal Grandfather – deceased at 80 y/o from Acute MI Paternal Grandmother – alive 76 y/o, HTN, rheumatoid arthritis Paternal Grandfather – 77 y/o, HTN, Type I DM ROS: General: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: Denies any vision changes, denies any watery or itchy eyes (“only when I get stung by a bee”) Ears, Nose, Throat: Denies hearing changes. Denies sneezing, congestion, runny nose or sore throat (“only when I get stung by a bee”). Skin: Denies any rashes or itching. Cardiovascular: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema. Respiratory: Denies any SOB, cough, or sputum production. Gastrointestinal: Denies any appetite changes, nausea, vomiting or diarrhea. Denies abdominal pain. Genitourinary: Denies dysuria and frequency. Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Denies changes in bowel or bladder control. Musculoskeletal: Positive for bilateral knee pain. Hematologic: No anemia, bleeding or bruising. Lymphatics: Denies any swelling in his groins. Psychiatric: Denies a history of depression or anxiety. Endocrinological: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Objective VS: BP 120/74; P 74; RR 22; T 36.7˚C; 02 96% (RA) Wt 65kg; Ht 65” General – TC appears well nourished, slightly overweight. Cardiovascular: Palpable dorsalis pedis, popliteal, and tibial pulses. Musculoskeletal: No deformities noted with active ROM. The McMurray test (Ball et al., 2019, p. 550 and LeBlond et al., 2015, p. 534) revealed both knees are stable to varus and valgus stress. Palpation ballottement test (Ball et al., 2019, p. 550) was negative for effusion/fluid. Tibial movement <5mm anteriorly and posteriorly with drawer test (Ball et al., 2019, p. 550). Childress duck-waddle test elicited pain and clicking. (LeBlond et al., 2015, p. 534). Positive Thessaly test (Ferri, 2019, p. 873), audible cracking and pain noted. Integumentary: Mild acne noted to face. Diagnostic results: Plain x-ray b/l lower extremities Assessment The knee is the largest joint in the body and comprises bone (femur, tibia, and patella), cartilage (menisci), and tendons (collateral and cruciate) (Papadakis & McPhee, 2019, p. 1709). Common trauma to the knee: strain – stretching/tearing of ligament, and muscle damage; sprain – stretching/tearing of tendon, and subluxation, or dislocation (Huether & McCance, 2017, Chapter 38). Differential Diagnoses Patellofemoral Syndrome (aka “runner’s knee” (Papadakis & McPhee, 2019, p. 1709)) The most common cause of outpatient visits with complaints of knee pain (Cahill, 2019). Common in young adults and athletes and occurs after long periods of rest or with activity (Cleveland Clinic, 2018). The patient will experience pain with active ROM (i.e. kneeling, squatting, climbing stairs) (Papadakis & McPhee, 2019, p. 1709). Pain is often gradual with an acute onset (Cahill, 2019). Meniscus injury Usually the result of an injury (i.e. twisting) (Ferri, 2019, p. 873). Swelling is present after injury (although can be absent) (Ferri, 2019, p. 873). Bursitis Pain associated with bursitis rarely limited ROM (Huether & McCance, 2017, Chapter 38). Osteoarthritis (OA) Unlikely as TC is 15 yo, OA is a disorder of synovial joints and a risk factor is increasing age; uncommon in patients under 40 y/o (Huether & McCance, 2017, Chapter 38). Plan This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. References Cahill, K. (2019). Ferri’s clinical advisor 2019 [e-book]. Elsevier, Inc. Cleveland Clinic. (2018, August 8). Patellofemoral pain syndrome (PFPS). Clevelandclinic.org. Retrieved April 15, 2020, from https://my.clevelandclinic.org/health/diseases/17914-patellofemoral-pain-syndrome-pfps Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination an interprofessional approach (9 ed.). Elsevier Mosby. Ferri, F. F. (Ed.). (2019). Ferri’s clinical advisor 2019. Elsevier. LeBlond, R. F., Brown, D. D., Suneja, M., & Szot, J. F. (Eds.). (2015). DeGowin’s diagnostic examination (10 ed.). McGraw Hill Education. Huether, S. E., & McCance, K. L. (Eds.). (2017). Understanding pathophysiology (6 ed.). Elsevier. Papadakis, M. A., & McPhee, S. J. (Eds.). (2019). Current medical diagnosis & treatment 2019 (58 ed.). McGraw Hill Education.
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