Advanced Health Assessment and Clinical Diagnosis in Primary Care

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Table of Contents

Episodic/Focused SOAP Note
ROS
O. Physical exam
Diagnostic results
References

Episodic/Focused SOAP Note

Patient Information: JA, 15, M, White

S.CC (chief complaint) – knee pain

HPI: Location: knee

Onset: 5 days ago

Character: dull, continuous, and catching

Associated signs and symptoms: clicking in knee and sensations under the patella

Timing: while walking and starting moving after sitting

Exacerbating/ relieving factors: running or going upstairs / at rest

Severity: 8/10 pain scale

Current Medications: Ibuprofen 800mg per day when the pain started

Allergies: anaphylaxis (bee sting)

PMH: Immunizations are up to date, the patient received influenza and tetanus vaccines last year; traumatic brain injury in 2014.

Soc Hx: Supports healthy lifestyle, including nutrition, jogging, and drinking enough water, denies ETOH or illicit drug use. He is a professional distance runner. The patient lives with their parents and studies at school, he lives in the city in a moderate crime area with good public transportation. He goes for routine care twice annually and as needed for episodic care.

Fam Hx: The only sister has arthritis dx at age 19. The mother is healthy, and the father presents hypertension and COPD (smokes).

ROS

GENERAL: No weakness, fatigue, or weight loss. The patient appears anxious yet oriented.

HEENT: Eyes: No changes in vision, no history of diplopia, glaucoma, floaters, photophobia, and excessive tearing. Ears, Nose, Throat: no recent tinnitus, ear infections, or discharge from the ears, the sense of smell is intact.

SKIN: No itching or rash.

CARDIOVASCULAR: No chest discomfort, palpitations, and history of murmur, arrhythmias, orthopnea, edema, or claudication.

RESPIRATORY: No dyspnea or cough.

GASTROINTESTINAL: No nausea, vomiting, or abdominal pain; no changes in bowel/bladder patterns.

GENITOURINARY: No change in urinary patterns.

NEUROLOGICAL: Periodical headache caused by stress; no syncopal episodes, dizziness, or paresthesia. No change in memory or thinking patterns.

MUSCULOSKELETAL: Knee pain, clicking, and sensations under the patella.

HEMATOLOGIC: No bleeding or anemia.

LYMPHATICS: No history of splenectomy; nodes are typical.

PSYCHIATRIC: Anxiety caused by pain.

ENDOCRINOLOGIC: No sweating, polyuria, or polydipsia.

ALLERGIES: Anaphylaxis (bee sting).

O. Physical exam

Vital signs: B/P 130/75, right arm, sitting, regular cuff; P 67 and regular; T 98.1 orally; RR 16; non-labored; Wt: 129 lbs; Ht: 5’7; BMI 22

General: NAD, A&O x3.

HEENT: PERRLA, EOMI, oronasopharynx is clear

Musculoskeletal: Symmetric muscle development; a full range of motion of legs and hands; uptight spinal column with iliac crests, shoulders, and skin creases below the buttocks; reflexes and extremities are adequate and symmetric; the knee is swollen; skeletal prominences are palpable at the joint margins, pain on resisted extension, effusion is mild, pain at lateral patella undersurface (Ball, Dains, Flynn, Solomon, & Stewart, 2015).

Diagnostic results

X-ray and MRI confirm swelling in joints (Dains, Baumann, & Scheibel, 2016; Sullivan, 2012).

Blood tests: Rheumatoid factor (RF) (n=6), high level of erythrocyte sedimentation rate (ESR) (52.5 mm/1st hour), and low C-reactive protein (CRP) (4.2 mg/dl) that show inflammation in the body.

Differential Diagnoses

Chondromalacia patellae. It is the wear of the cartilaginous joint (the lower part of the calyx) that manifests itself in cases of a strong increase in the friction of the patella on the hip bone during the (movement) of the knee (Salehi-Abari, Khazaeli, & Niksirat, 2015). Chondromalation of the patella of the first degree is manifested by bloating cartilage and small soft thickenings. At such times, the patient feels unpleasant sensations in the area of the lesion. All the symptoms correspond to those of the patient.
Rheumatoid arthritis. It is an autoimmune disease of unknown etiology that is one of the varieties of chronic arthritis, which differs in affecting the joints on both sides of the body. Sometimes the disease leads to the fact that the cartilage, ligaments, as well as bones, are destroyed, and the joint is strongly deformed even at the initial stage of the disease (Pap & Korb-Pap, 2015).
Osteoarthritis. It occurs as a result of mechanical destruction of joint structures, changes in the capsule, and damage to the cartilage due to immunity weakness (Pap & Korb-Pap, 2015). Osteoarthritis most often affects large joints of the knee, femoral, and spine.
Fibromyalgia. It is the disease, according to which a patient has a sense of musculoskeletal indisposition expressed in fatigue and stiffness of movements that can appear throughout the body (Clauw, 2014).
Lyme Disease. It is an infectious disease that occurs due to bites of ticks characterized by symptoms of intoxication and a typical skin rash called migratory erythema (Nelson et al., 2015).

Treatment should begin with conservative methods such as rest, medication, and changes in the training regimen. Ibuprofen 200 mg every 6 hours should be prescribed to address pain. After that, a rehabilitation program should be appointed based on the stretching of the extensor muscles, the iliac-tibial tract, the ligaments that hold the patella, and the back of the hamstrings. Arthroscopy of the knee joint may be conducted to eliminate inflammation. If treatment with the above methods did not produce any results, then the patient should be prescribed a surgical procedure. For cartilage regeneration, implantation of own chondrocytes, transplantation of bone-cartilaginous auto- or allograft, and plastic with a fragmented bone-cartilaginous graft are performed. To prevent chondromalacia patella, it is possible to recommend wearing shoes equipped with orthopedic inserts.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Clauw, D. J. (2014). Fibromyalgia: A clinical review. JAMA, 311(15), 1547-1555.

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.

Nelson, C. A., Saha, S., Kugeler, K. J., Delorey, M. J., Shankar, M. B., Hinckley, A. F., & Mead, P. S. (2015). Incidence of clinician-diagnosed Lyme disease, United States, 2005–2010. Emerging Infectious Diseases, 21(9), 1625-1631.

Pap, T., & Korb-Pap, A. (2015). Cartilage damage in osteoarthritis and rheumatoid arthritis—two unequal siblings. Nature Reviews Rheumatology, 11(10), 606-615.

Salehi-Abari, I., Khazaeli, S., & Niksirat, A. (2015). Chondromalacia patella and new diagnostic criteria. Open Science Journal of Clinical Medicine, 3(4), 126-138.

Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis Company.