Musculoskeletal Pain Assessment: Knee
Demographic data
Name of the patient: C.F
Age: 15 years
Gender: male
Subjective Data
Chief complaint: Patient came accompanied by the mother to the health care facility with the chief complain of a dull pain in both the knees that is always accompanied by a catching sensation under the patella and clicking of both knees whenever the patients try to move. The assessment will be done for the chief complain using OLDCARTS
O=Onset of the symptoms of pain, in this case, is acute
L= Location of the pain in this case at the patella of both knees
D= Duration, in this case, is recent and three days ago
C=Character of the pain, in this case, is a dull pain
A=Associated symptoms which in this case is clicking of both knees and catching sensation under the patella
R= Relieving factors, in this case, is resting
T=Treatment, in this case, is Aspirin and ibuprofen
S=Severity of the pain, in this case, will be assessed in the scale of 1-10.
History of the presenting illness
C.F is a 15 years old male who presented to the health care facility with pain on the knees for a duration of 3 days. The knee pain is associated with the clicking of both knees and a sensation that is catching under the patella. The patient used aspirin with since the onset of the pain, and he has been of ibuprofen every time he felt pain over the knees.
Allergies: the patient denies allergies to medication, food, nor any other allergens like dust and cold.
Past medical history: none
Past surgical history: none
Sexual and reproductive history: Confesses not to be sexually active but tries out sex with one girl who is his girlfriend, when he feels like doing so.
Personal and social History: He is a participant in a school competition where he participated the most in soccer. He does not use any recreational drugs.
Immunization History: All the immunization up to date have been administered according to the mother. He received the flu vaccine in 5th July 2017, and he received tetanus toxoid six months down the line.
Significant family history: Maternal grandmother is suffering from hypothyroidism. The paternal grandmother is a survivor of breast cancer, and both grandfathers from both maternal and paternal side have diabetes.
Lifestyle: C.F. is the firstborn in a family of three children with a sibling who is both girls, well and alive. Both parents are both active. He loves playing soccer in school and participating in swimming. Besides, he enjoys music the most and is looking forward to the day he will begin to drive.
Review of systems
General: C.F. has complained of dull pain in both knees that is associated with clicking and catching sensation under the patella. He claims that his symptoms were aggravated by physical activity. There is slight tenderness, swelling, and reddening of the knees.
HEENT: Patient denies loss of vision, loss of hearing, epistaxis, and headaches. He had seen the dentist one month ago.
Respiratory: He denies hemoptysis
Cardiovascular: Denies chest pain.
Gastrointestinal: no constipation and no abdominal pain.
Genitourinary: Denies incontinence and no penile discharge.
Musculoskeletal: Dull pain in both the knees that is always accompanied by a catching sensation under the patella and clicking of both knees.
Psychiatric/ cognitive: no depression, no mood swings
Neurological: no seizures, no balance problems, no coordination challenges
Skin: denies skin lesions, no rashes, denies moles
Hematologic: denies epistaxis, gum bleeding and eye and skin bruising
Endocrine: denies tremors and excessive urination and thirst
Immunologic: denies asthma
OBJECTIVE DATA
General: Well build and well-nourished, alert, and cooperative. He talks fluently and answers every question asked.
Vital signs: BP 120/68mmHg, Pulse 64, RR 16breths per minute, and temporal temperature of 98.8, height 5 feet and weight 160.
HEENT:
Neck: Full range of motion
Chest: Normal diaphragmatic excursion and chest wall expansion.
Lungs: On auscultation, breath sounds are healthy in all lung fields.
Heart: On auscultation, heart rate and rhythm are normal. There are no heart murmurs: S1 and S2 present.
Abdomen: no tenderness, no enlargement, no hernia. Bowel sound heard and they are normal in all the four quadrants.
Musculoskeletal: mild swelling, tenderness, and warmth in both knees. Can fully bear and carry his weight. Negative Homan’s sign and negative McMurray test (Dains, Baumann & Scheibel, 2016). Positive Lachman test.
Neurological: Mood and affect congruent. Alert and oriented to time, place, and person.
Skin: Intact skin
Diagnostic tests: MRI radiograph while the knee is rotated inwards to help in ruling out the fractures.
X-ray help is inspecting for patella dislocation
Assessment and Differential diagnosis
Priority diagnosis: Osgood Schlatter disease
It is a disease that affects young people mainly. The condition causes the swelling of the anterior tibial tubercle that is painful (Seidel et al., 2011). The pain is aggravated by activities such as walking for long-distance, climbing stairs, physical activities and kneeling. Positive Lachman test is the best indicator of the disease.
Differential diagnosis
Baker yeast: This is a condition in which the posterior knee swells and is always aggravated by walking for a long distance.
Medial meniscus- Mainly occurs when a patient has a history of injury to the knee that was twisting to the knee. Also, the patient presents with pain over the knee, clicking and catching of the knees on movement.
Osteogenic Sarcoma: This is a disease of the knee that causes tenderness and intermittent pain over the upper part of the tibia and the affected area. According to (Seidel et al., 2011) Osteogenic Sarcoma is always affecting people within the age of 10-25 years.
Sciatica: A disease causes a sharp pain that starts from the back and radiates to the lateral leg and the foot (Health Line, February 15, 2017).
References
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.
Health Line. (February 15, 2017). Knee pain: Causes, Symptoms, and Diagnosis. Retrieved on April 17, 2017, from http://www.healthline.com/health/pain-relief/knee-pain-stairs#Prevention5.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for musculoskeletal assessment. In Mosby’s
