NURS 6512 Discussion Review of Case Study 3, Assessing Musculoskeletal Pain
NURS 6512 Discussion Review of Case Study 3, Assessing Musculoskeletal Pain
Episodic Focused SOAP Note:
Chief Concern (CC): I’ve been having dull pain in both of my knees, and I have also noticed that my knee and sometimes both of them click.”
History of Physical Illness (HPI): 15-year-old male patient presents today with a history of dull pain in both knees. The patient is concerned that one or both knees intermittently click, and he feels something catch below the patella (Walden University, n.d.).
Additional History Needed to Determine Cause of Knee Pain:
As a future APRN, it would be important to know if the patient’s pain is acute or chronic. I would use a mnemonic, such as OLDCARTS, to guide me as I interview the patient (Ball et al., 2019). Questions that I would want to know from the patient would include: Does the clicking sound occur with knee movement? How often does the clicking sound occur? Has the patient sustained any recent injuries? I would be interested to know what makes the pain worse and better. Additionally, I want to know the treatments the patient has used for his knee pain (e.g., rest, ice [or heat], elevate, immobilize, non-steroid inflammatory drugs, or acetaminophen). I would conduct the interview with the parent or caregiver out of the room, and then with the patient’s permission, ask the parent for more information.
Categories to Differentiate Knee Pain:
There are different categories to differentiate knee pain: bones, cartilage, ligaments, muscles, and tendons (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], n.d.). Each of these categories has conditions with clinical presentations, such as arthritis (bones and cartilage), chondromalacia and meniscus injury (cartilage), anterior and posterior cruciate ligaments injuries (ligament), tendinitis (tendon), and more (NIAMS).
• Name, dosage, frequency, indication for taking medication, and last dosage should be noted.
• Medications should include prescribed, over the counter, vitamins, minerals, supplements, and complementary alternative medications (Ball et al., 2019).
Past Medical History (PMH):
• Recent trauma
• Connective tissue disorders (e.g., Marfan’s syndrome)
• Juvenile Rheumatoid Arthritis
• Neuromuscular disorders
• Neurological disorders
Past Surgical History (PSH):
• Orthopedic surgeries or procedures, such as arthroplasty
Family History [FH]: (Ball et al., 2019)
• Abnormalities of the hips, knees, or feet
• Osteogenesis imperfecta
• Marfan’s Syndrome
Social History (SH)
Information needs to be collected regarding the patient’s usage of tobacco products, alcohol, or illicit drugs. It is essential to get a baseline assessment of the patient’s usual activity of daily living. Is the patient involved in organized sports (e.g., soccer, football, baseball, basketball, martial arts)? I would also gather information about the patient’s average diet, including a balanced diet with protein and nutrients to help heal his condition.
• Allergies to prescribed medications, over-the-counter medications, vitamins, minerals, and supplements should be noted with the type of reaction and severity.
• Review of current immunizations that should include last T-dap, Influenza, and COVID-19 boosters, and vaccines.
Review of Systems (ROS)
• Recent fatigue, malaise, fever, chills, night sweats, unusual bruising, unusual bleeding, and unintentional weight loss will need to be asked of the patient.
• Inspection, percussion, palpation, and auscultation of the heart are part of all focused episodic exam.
• Inspection, percussion, palpation, and auscultation of the lungs are also part of a focused episodic exams.
• Inspection, percussion, palpation, and auscultation of both knees will be performed.
Physical Examination Performed (Ball et al., 2019)
• Inspect knees for symmetry, concavity, and contour in the flexed and extended positions.
• Observe the patient’s lower legs for alignment, specifically the femur and tibial angle should be at or less than 15 degrees to rule out either genu valgum or genu varum.
• Palpate popliteal and joint space in the flexed and extended positions.
• Test the patient’s range of motion (e.g., flexion-130 degrees, extension-0 to 15 degrees).
• Test the patient’s strength during flexion and extension while providing oppositional force against movement.
Anatomic Structures Being Assessed (Ball et al., 2019)
• Anterior and Posterior Cruciate Ligaments
• Lateral and Medial Ligaments
Special Maneuvers Performed (Lee et al., 2017; Ball et al., 2019)
• Hughston’s Plica Test
• Strutter Test
• Ballottement test
• Bulge test
• McMurray Test
• Apley Test
• Thessaly Test
• Anterior and Posterior Drawer Test
• Lachman Test
• Varus and Valgus Stress Tests
Vital Signs: (VS) height, weight, body/mass index (BMI), or vital signs
General: patient’s race, patient’s preference for gender identity will be ascertained.
Cardiovascular: The patient’s heart sounds (e.g., nl S1, nl S2, S3, S4), murmurs (e.g., type and location), adventitious sounds, clubbed fingers, capillary refill, jugular vein distension, carotid bruits or thrills, pedal edema would be noted in this section.
Pulmonary: Breath sounds in all areas of the anterior and posterior lungs (e.g., bronchial, bronchovesicular, vesicular, dull, resonant, and hyper-resonant) would be noted.
Musculoskeletal- symmetry, skin condition (e.g., bruising), swelling, pain with range of motion, and effusion around knee should be noted.
• Radiograph of knees would be indicated this patient if it was determined his condition was secondary to an acute knee injury with the following findings: tenderness at fibula head, patella tenderness that is isolated, and the inability of the patient to flex his knee at a 90-degree angle (Ball et al., 2019). The patient has bilateral knee pain, which decreases the probability of malignancy; however, I would consult with my preceptor regarding ordering X-rays of his knees to rule out bony pathology.
• An MRI may be indicated if the patient has an injury to the medial or lateral meniscus and to the anterior or posterior cruciate ligaments (Rastegar et al., 2016). I would consult with my preceptor if the patient had a positive McMurray test before ordering an MRI. Additionally, if the patient’s symptoms did not improve with therapy, I would again consult with my preceptor about ordering an MRI for this patient.
• CBC with differential-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Sedimentation rate-if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Anti-nuclear antibody test- if indicated depending on the patient’s H&P (Thatayatikom, 2021).
• Rheumatoid factor- if indicated depending on the patient H&P’s (Thatayatikom, 2021).
Differential Diagnosis according to Song et al. (2018); Lee et al. (2017):
1. Synovial Infrapatellar Plica Syndrome of the knee is associated with anterior knee pain and clicking or popping sounds (Casadei & Kiel, 2021). The authors report that plica, a thick fibrotic band of tissue extending from a synovial joint, most commonly the knee[s] becomes inflamed due to overuse. Bilateral anterior knee pain is common. This patient has clicking sounds with pain around the knees. This diagnosis needs to be supported by more evidence from the history and physical of the patient.
2. Medial or Lateral Meniscal Tears are associated with knee sounds such as clicking, catching, and locking around the knee (Bhan, 2020). The author reports meniscal tears are common, and MRIs are inevitably required to confirm a diagnosis. This patient has bilateral clicking noise and a sensation of catching to the back of his knees.
3. Patellar Tendinopathy, commonly referred to as ‘Jumpers Knee’ is caused by small tears to the patella tendon that can be painful (Santana et al., 2021). The authors note this condition is seen with sporting activities that require jumping. The patient is complaining of dull pain in both knees. It is essential to gather more subjective and objective data from this patient and possibly his parents for an accurate working diagnosis.
4. Patellofemoral pain syndrome is characterized by anterior knee pain reproduced with running, climbing, and squatting (Bump & Lewis, 2021). The authors report patients generally describe an achy pain located around the knee. This diagnosis is part of the differential because the patient is experiencing pain around the knee. However, more information is required to give a presumptive diagnosis.
5. Anterior Cruciate Ligament Sprain or Tear is considered the most common injury to a knee ligament associated with sporting activities such as football, soccer, and basketball (Evans & Nielson, 2021). The authors state that the injury sustained to the ACL is most commonly a non-contact injury seen with skiers, soccer players, and basketball players from rotational movements. Patients generally complain of a popping sound and the knee giving out (Evans & Nielson). The patient is not complaining of a popping sound but rather a clicking sound with a catching sensation under the patella. This diagnosis is less likely because of the patient’s clinical presentation.
6. Juvenile Rheumatoid Arthritis (JRA) is diagnosed in patients younger than 16 years of age with joint and soft tissue pain (Thatayatikom, & Modica, 2021). An inflammatory, autoimmune process must be considered, especially if there is a family history of autoimmune disorders.
7. Osteochondrosis is also known as Osgood Schlatter disease, is a frequent cause of adolescent knee pain (Smith & Varacallo, 2020). The authors state it is caused by repetitive athletic movements seen more often in boys 12 to 14 years of age. They report that patients complain of anterior knee pain caused by microvascular tears and swelling when a piece of the tendon pulls away from the patella (NIAMS, n.d.). This diagnosis is less likely because the patient is complaining of dull bilateral pain to the knees, and he is not complaining of a bony bump to his kneecap, which is common with this disorder.
Primary Diagnosis/Presumptive Diagnosis
• Synovial Infrapatellar Plica Syndrome.
This section is not required for the assignment in this course (NURS 6512) but will be required for future courses.
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, (9th ed.). Elsevier.
Bhan, K. (2020). Meniscal tears: Current understanding, diagnosis, and management. Cureus,
12(6), e8590. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359983/
Bump, J.M., & Lewis, L. (2021, May 8). Patellofemoral syndrome. In: StatPearls. StatPearls
Casadei, K., & Kiel, J. (2021, April 19). Plica syndrome. In: StatPearls. StatPearls Publishing.
Evans, J., & Nielson, J.L. (2021, February 19). Anterior cruciate ligament knee injuries. In:
StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499848/
Lee, P., Nixon, A., Chandratreya, A., & Murray, J.M. (2017). Synovial plica syndrome of the
knee: A commonly overlooked cause of anterior knee pain. Surgery Journal, 3(1), e9-e16. https://doi.org/10.1055/s-0037-1598047
National Institute of Arthritis and Musculoskeletal and Skin Diseases. (n.d.). Knee problems.
Rastegar, S., Motififard, M., Nemati, A., Hosseini, N.S., Tahririan, M.A., Rozati, S.A., Sepiani,
M., & Moezi, M. (2016). Where does magnetic resonance imaging stand in the diagnosis of knee injuries? Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences, 21,(52). https://doi.org/10.4103/1735-1995.187256
Santana, J.A., Mabrouk, A., & Sherman, A.L. (2021, March 17). Jumpers Knee. In: StatPearls.
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532969/
Smith, J.M., & Varacallo, M. (2020, July 29). Osgood Schlatter disease. In: StatPearls,
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441995/
Song, S.J., Park., C.H., Liang, H., & Kim, S.J. (2018). Noise around the knee. Clinics in
Orthopedic Surgery, 10(1), 1-8. https://doi.org/10.4055/cios.2018.10.1.1
Thatayatikom, A., & Modica, R., & de Leucio, A. (2021, January). Juvenile idiopathic arthritis.
In: StatPearls, StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK554605/
Walden University. (n.d.). Case 3: Knee pain: Advanced health assessment. www.waldenu.edu.
Case 3: Knee Pain
Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.
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?