Assessing Muscoskeletal Pain

AssessingMuscoskeletal Pain

Subjective– history section

  • Patient said he had fallen on a hard surface

  • He complains of a catching sensation beneath the patella after moving the joint

  • No family member suffers from a a condition

  • He is neither a soccer player nor an athlete

Objective

  • He has well toned muscles that indicates intensive daily workouts

  • The family genealogy looks healthy

  • Knee has healed scars that indicates he had once sustained serious knee injury

  • Observable pain upon moving the knee

  • Kneecap in place

  • No inflammation noticeable

  • Takes no prescription drugs

  • All the essential tests such as Xrays and collection of sample liquid from the patient’s knee completed on the first day

Assessment

  • For diagnosing knee pain, an X-ray of the knee is essential to determine the position of the bones

  • The next process will involve evaluation whether the knee muscles are in place.

  • Finally, compatible history in the family may also help to reach the diagnosis findings (LeBlond, Brown, &amp DeGowin, 2009).

  • Since the boy complains he has a dull pain beneath the patella, the physician should examine if the bursa pockets are in position.

  • Therapists should also look for detached ligaments as well as the disposition of the kneecap.

  • Finally, the doctor should test the presence of bacteria or viruses that may cause inflammation of the tendons around the knee (Seidel, Ball, Dains, Flynn, Solomon, &amp Stewart, 2011).

Plan

  • Recommend suitable prescription medication for suppressing the pain

  • Propose a one month bed rest to allow damaged tissue around the knee to heal

  • Enroll in special knee-training programs that would help them to recover from the injury (Seidel et al., 2011).

  • Prepare for surgery in case there is no noticeable improvement recorded after the one month of medication and body training

References

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

Dains,J. E., Baumann, L. C., &amp Scheibel, P. (2012). Advancedhealth assessment and clinical diagnosis in primary care (4th ed.).St. Louis, MO: Elsevier Mosby.

LeBlond,R. F., Brown, D. D., &amp DeGowin, R. L. (2009). DeGowin’sdiagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

Seidel,H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &ampStewart, R. W. (2011). Adultexamination checklist: Guide for musculoskeletal assessment.In Mosby`s guide to physical examination (7th ed.). St. Louis, MO:Elsevier Mosby.

AssessingMuscoskeletal Pain

Institutionof Affiliation

Subjective:

cc:“Pain in the both knees of the patient.”

HPI:a 15y/o male presents with dull pain in both knees, the patientcatches sensation under the pallet. Sometimes the patientexperiences clicking of the knees in one or both knees.

Thepatient has been taking over the counter painkillers, aspirin thathave helped with the pain.

Allergies:No allergies

PSH:Has never undergone any surgery.

Personal/SocialHistory: The patient “plays soccer” most of his free times. He“engages in a lot of other physical activities.”

Immunizationhistory: the patient was immunized last as a child. He “doesn’thave a problem” with injections as well as oral vaccination.

Lifestyle:He is a high school student and is part of the school team. Thepatient denies any past injuries on the knees. He is an athletic andenergetic individual.

Objective:

Physicalexamination:

General:G.E. is a 15-year-old healthy, energetic and well-developed male. Heis a jovial person who cracks jokes even when in pain.

Vitals:He has well-toned muscles that indicate intensive daily workouts. Theknee has healed scars that indicate he had once sustained a seriousknee injury in the past. There is an observable pain upon moving theknee and the kneecap in place.

DiagnosticData: All the essential tests such as X-rays and collection of sampleliquid from the patient’s knee completed on the first day. Nonoticeable inflammation.

Differentdiagnosis:

  1. The patient had minimal loss of passive knee ROM

  2. Pain with restricted knee extension that was tested with the knee in at different temperature intervals (0/30/60/90 degrees)

  3. Minimum effusion

  4. Dips became painful with few reps

  5. Compression for the patella into the femoral trochlea made the patient feel pain

Assessment:

Probablebursitis, Osgood-Schlatter disease, patellar tendonitis, orIliotibial band syndrome

Overuseof fluid.

Afall

Repeatedbending and kneeling

Plan:

Recommendsuitable prescription medication for suppressing the pain

Proposea one-month bed rest to allow damaged tissue around the knee to heal

Enrolin special knee-training programs that would help them to recoverfrom the injury (Seidel et al., 2011).

Preparefor surgery in case there is no noticeable improvement recorded afterthe one month of medication and body training

Forone to discern the most appropriate diagnosis for this patient’sknee pain, one should use the following questions:

Doyou recall any injury on your knees in the past?

Howdo you feel after a long, vigorous exercise, does the pain come ordoes it go away?

Doyou experience any such pains in other joint parts of the body?

Conclusion

Inconclusion, the patient is most likely suffering from bursitis,causing him to experience knee pains. The patient admits he likesplaying soccer as well as engaging in other physical activities.These may be what caused the overuse of the knee fluid due torepeated bending of knees when performing these activities. Resettingthe knees, by avoiding intense activity for some time, is anappropriate way of treating the problem.

References

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

Dains,J. E., Baumann, L. C., &amp Scheibel, P. (2012). Advancedhealth assessment and clinical diagnosis in primary care (4th ed.).St. Louis, MO: Elsevier Mosby.

LeBlond,R. F., Brown, D. D., &amp DeGowin, R. L. (2009). DeGowin’sdiagnostic examination (9th ed.). New York, NY: McGraw Hill Medical.

Seidel,H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &ampStewart, R. W. (2011). Adultexamination checklist: Guide for musculoskeletal assessment.In Mosby`s guide to physical examination (7th ed.). St. Louis, MO:Elsevier Mosby.