TO WRITE 1 COMMENT TO EACH POST WITH 2 CREDIBLE REFERENCE ABOVE 2013.
XX, 15yo, Male
CC: “Dull pain, both knees”
Location: Both knees (would ask him to point to the exact location)
Onset: NA (would ask if onset was sudden or gradual, was he doing an activity when it occurred)
Character: Dull, catching, clicking
Associated signs and symptoms: NA (would ask if the pain wakes him up at night, what activities are limited due to the knee pain, can he straighten or bend the knees)
Timing: NA (would ask when the pain occurs)
Exacerbating/ relieving factors: NA (would ask what makes it worse, what makes it better)
Severity: NA (would have pain rated on a scale of 0-10)
Current Medications: NA (would ask what medication he is on if any)
Allergies: NA (would ask if any medication or food allergies)
PMHx: NA (would ask about general health, past illnesses, past surgeries, hospitalizations, immunizations, any blood transfusions, any psych history)
Soc Hx: NA (would ask if he works, and where, does he play sports and if so what and how often, does he smoke, does he drink alcohol, does he do any illicit drugs, does he drink caffeine, if so how much and how often for each, has he lost or gained any weight, does he follow a specific diet, and what about exercise) I would also ask if he uses sports safety equipment if he plays in sports, does he wear a seatbelt, does he ride with others that may be impaired by drugs or alcohol.
Fam Hx: NA (would ask about parents, grandparents, sibling health history and any deaths, ask about cancer, cardiac diseases, diabetes)
GENERAL: NA (would ask if any weight loss, fever, chills, weakness or fatigue)
HEENT: NA Eyes, Ears, Nose, Throat (would ask if any drainage, problems, blurred vision, problems swallowing etc.)
SKIN: NA (would look for skin rashes, moles, or open wounds)
CARDIOVASCULAR: NA (would ask about heart problems, blood pressure, swelling to lower extremities)
RESPIRATORY: NA (would ask about shortness of breath, cough or sputum)
GASTROINTESTINAL: NA (would ask about anorexia, nausea, vomiting or diarrhea. abdominal pain or blood)
GENITOURINARY: NA (would ask about burning on urination, would address sexual activity/protection)
NEUROLOGICAL: NA (would ask about headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, changes in bowel or bladder control)
MUSCULOSKELETAL: unilateral to bilateral knee pain, clicking, and catching under the patella, (would further ask if he had any limping at time of knee pain, any back pain, joint pain or stiffness)
HEMATOLOGIC: NA (would ask if any anemia, bleeding or bruising)
LYMPHATICS: NA (would ask if patient noticed any enlarged nodes or has a history of splenectomy)
PSYCHIATRIC: NA (would ask if any history of depression or anxiety)
ENDOCRINOLOGIC: NA (would ask if any sweating, cold or heat intolerance, polyuria or polydipsia)
ALLERGIES: NA (would ask if history of asthma, hives, eczema or rhinitis)
Physical exam: knee checks I would perform are:
Overall look of knee color, swelling, temperature of skin to palpation, and patient vitals to monitor for fever.
Complete Blood Count to monitor white count to look for infection. Estimated sed rate to look for inflammation. (Dains, Baumann, and Scheibel, 2016)
Radiography 4 view film of knee for an anteroposterior, lateral, tunnel, and a 30-degree sunrise view of the patella. (Dains, Baumann, and Scheibel, 2016) Radiography films would help view knee, ligaments, and bone to view for injury. May also need a knee Ultrasound. Use of magnetic resonance imaging or computed topography scan would be utilized if no answers obtained from physical exam and preliminary diagnostic tests.
Bates, N. A., Nesbitt, R. J., Shearn, J. T., Myer, G. D., & Hewett, T. E. (2015). Relative strain in the anterior cruciate ligament and medial collateral ligament during simulated jump landing and sidestep cutting tasks. American Journal of Sports Medicine, 43(9), 2259-2269. doi:10.1177/0363546515589165
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
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XX, 42, Male
CC: “lower back pain”
HPI: 42 year old male who reports having pain in his lower back for the past month, which radiates to his left leg at times.
Onset: 1 month
Associated signs and symptoms:radiates to left leg at times
Exacerbating/ relieving factors: unknown
Current Medications: Unknown
Soc Hx: Unknown
Fam Hx: Unknown
Diagnostic results: Please note, diagnostic testing is not warranted without the first four week for the onset of back pain if neurological symptoms are not present (Dains, Baumann, & Scheibel, 2016, p. 295).
Additional Interview Questions
Obtain vital signs and determine if a fever is present. The presence of a fever could indicate an infectious or inflammatory process. Also determine if there has been any recent weight loss, intravenous drug use, or underlying immunosuppression (Dains, Baumann, & Scheibel, 2016, p. 288).
Determine if the patient has undergone any recent trauma to the spinal cord that could have caused a fracture, dislocation, or sore muscles. Further assessment of the patient’s occupation and any possible strain to the lower back during day to day actives. Also inquiring about any existing medical conditions that the patient may have (Dains, Baumann, & Scheibel, 2016, p. 289).
Systemic diseases, such as cancer and fibromyalgia should be ruled out. Furthermore, if the patient has an underlying diagnosis of cancer, tumor development on the spinal cord is at an increased risk (Dains, Baumann, & Scheibel, 2016, p. 289).
Assessing the patient’s bowel and bladder function could signify nerve root compression related to a herniated disk, a nerve root entrapment, spinal stenosis, infection, or tumor. The incontinence of the bowel and bladder could indicate the presence of cauda equina syndrome (Dains, Baumann, & Scheibel, 2016, p. 290).
A complete list of the patient’s medications could lead the advanced practice registered nurse (APRN) to possible lower back pain causes. For example, if the patient was using illegal intravenous drugs, an infectious process could have set it and could be affecting the back (Dains, Baumann, & Scheibel, 2016, p. 290).
Obtaining detailed information about the back pain will aid the APRN in the cause of the back pain. Further information to obtain would include, characteristic of the pain, aggravating factors, and alleviating factors. A thorough assessment would also include questions asked about balance and gait changes. The APRN would also ask about the presence of numbness and tingling in the back or other extremities (Dains, Baumann, & Scheibel, 2016, p. 291-292).
Additional Physical Examination
Observe the patient’s overall appearance and movement. By watching the patient move you can determine asymmetrical movement that may be related to his underlying diagnosis. Vital signs will help determine an infectious process. Assess the skin looking for signs of a tumor or dermal cyst. Abnormalities of the head, eyes, ears, norse, and throat could signify an infectious process. By inspecting the back and extremities the APRN can assess for spinal alignment symmetry of both sides of the body. Percussion of the back and spine could uncover scolioses and would identify tenderness.Range of motion testing will help identify lumbar mobility. Furthermore, an examination of the hip should include mobility, muscle strength, muscle circumference, neurological sensory function, deep reflexes and an assessment to the abdomen (Dains, Baumann, & Scheibel, 2016, p. 294-295).
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