He enjoys video games and making Tik Tok videos with his brother.
11 hours ago
Laura Walton
Review of Case Study #3
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Episodic/Focused SOAP Note Template
Patient Information:
Z.W. 15-year-old AA male
S.
CC: Patient c/o “dull pain in both knees, intermittent clicks/ catching under patella”
HPI: Z.W. is a 15-year-old African American male who presents to the clinic with complaints of dull pain in both knees. Pt. reports sometimes one or both knees click and describe a catching sensation under the patella. Pt. states he noticed the pain after baseball practice 1 week ago. He denies falling or injuring his knees during practice. He uses heat packs to control pain and his mom gives him Tylenol 650mg tablets. He rates his pain 8/10 Tylenol relieves pain to 2/10.
Current Medications: Tylenol 650mh tabs as needed last doses last night
Zyrtec 10mg po as needed seasonal allergies
Allergies: Strawberries hives
PMHx: Tonsillectomy 2016
Current immunizations including HPV and influenza
Soc Hx: ZW lives with both parents and brother he’s in the 9th grade and has lots of friends he plays baseball, football and basketball. He’s an honor student. He enjoys video games and making Tik Tok videos with his brother. He denies alcohol or recreational drug use. He wears his seat belt when riding with his family or friends.
Fam Hx: mother: HTN, DM, obesity Father: HTN
Maternal grandmother: DM, obesity maternal grandfather: Cataracts
Paternal Grandmother: HTN Paternal grandfather: dementia
Brother: 21 obesity
ROS:
GENERAL: Pt. is appropriately dressed rubbing knees with facial grimacing during assessment. Mother present
HEENT: Appropriate symmetry, weight and height appropriate with glasses no problems hearing
SKIN: Skin warm and dry no rashes mild edema noted to bilateral knees
CARDIOVASCULAR: RRR no murmurs normal S1-S2
RESPIRATORY: lungs clear no wheezing no SOB no cough
GASTROINTESTINAL: Denies n/v regular bowel movements no abd pain
GENITOURINARY: no voiding difficulties
NEUROLOGICAL: denies numbness, tingling, no headaches or episodes of dizziness
MUSCULOSKELETAL: Equal ROM able to bend knees able to hop on one leg alternating no c/o back pain no c/o ankle or hip pain
HEMATOLOGIC: no bruises no abnormal bleeding
LYMPHATICS: No swollen lymph nodes upon assessment
PSYCHIATRIC: Denies being sad or depressed in the past couple of weeks
ENDOCRINOLOGIC: No abnormal sweating no excess thirst or urinating
ALLERGIES: Strawberries
O.
Physical exam: 97.5-82-16-120/74 98% 185lb 5’8” BMI 28
General: Z.W. appropriately height and weight physically active teenager
Skin: no rashes no bruises
HEENT: Symmetrical head, ears wears glasses no c/o ear pain no wax noted oral dentition braces noted
Neck: Full ROM no swollen lymph nodes no goiter
Respiratory: lungs clear equal rise and fall of chest no sob no wheezing
Cardiovascular: S1-S2 no murmurs
Breast: no deferred
Abdomen: no tenderness, soft hyperactive bowel sounds
Genitalia: deferred
Rectal: deferred
Musculoskeletal: (knees) mild +1 edema bilaterally no redness full ROM, full weight bearing
Neurological: Alert and oriented x3 denies headaches, dizziness
Diagnostic results:
McMurray test to detect meniscus injury (Fenstermacher, 2016)
Lachman test to determine integrity of ACL
Varus stress test to determining stability of LCL
-Push calf laterally (abduction)
Valgus stress test to determine stability of MCL
-Push calf medially (adduction) (Fenstermacher, 2016)
X-Ray of bilateral knees
CBC rule out septic joint
RF to rule out rheumatoid arthritis
MRI (Kiel & Millelsen, 2018)
A.
Differential Diagnoses
Bilateral meniscal tear-injuries often cause gradual effusion; however recurrent swelling after strenuous activity is also linked to meniscal trauma (Maldonado, 2019)
Tibial plateau fracture-common difficult to manage injuries that can be due to high or low energy trauma
Septic join-infection in a joint space
Rheumatoid arthritis-joint tenderness, pain and swelling
Patellofemoral pain syndrome-cartilage under the kneecap is damaged due to injury or overuse
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Camacho-Carrasco, P. P.-F. (2016). Treatment strategy for tibial plateau fractures: an update. Retrieved from ncbi.nlm.nih.gov
Fenstermacher, K. H. (2016). Practice guidelines for family nurse practitioners 4th ed. St. Louis, MO: Elsevier.
Kiel, C., & Millelsen, K. K. (2018). Why tibial plateau fractures are overlooked. BMC Musuloskeletal Disorders , 19 (244).
Maldonado, D. Z. (2019). SOAP for family medicine 2nd ed . Philadelphia: Wolters Kluwer .
PLEASE REPLY TO POST WITH 3 EDUCATIONAL ARTICLE LESS THAN 5YRS OF AGE
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