Answer Discussion1 essay paper

Answer Discussion1

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A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining  Discussion1the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?

answer based on this:
Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning.

Patient Information: Answer Discussion1
JS, 15, M, Caucasian
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CC (chief complaint): “Knee Pain”
HPI: Mr. Smith is a 15-year-old Caucasian male who came in with knee pain for two months after having a “buggy accident” which got worse this morning. The pain is described as a dull ache and is rated a four out of ten in terms of intensity. The pain is in the knee with a catching sensation under the patella. The patient reports no nausea, vomiting, photophobia, or phonophobia. The patient reports playing softball makes it worse. The patient has taken NSAIDS and resting in bed with little relief.
Current Medications: Multivitamin daily Answer Discussion1
Allergies: Seasonal Allergies (Sneezing, Hives); Food: Bananas (Hives); PCN: (anaphylaxis)
PMH: Patients mother denies childhood vaccinations for religious reasons. The patient has not had any vaccinations in his lifespan. Denies covid vaccinations. Denies influenza and pneumonia vaccinations. Answer Discussion1

Soc Hx: The patient lives in an Amish community with his mother and father. The patient is homeschooled and plays community softball. The patient denies tobacco and alcohol use. The patient lives in a smoke-free home. Patient states that “we do not own a car; we use a horse and carriage;” therefore, no seat belts are available. Patient does not have access to a phone or technology. Patient participates in “buggy races” for fun on the weekends. Patient states he is not sexually active. Patient primary language is English. Patient denies recreational drug use. Patient states he does not work out in a gym but does farm work from 0400-1500 with breaks throughout the day. Patients diet is balanced well with his vegetables and meat from their farm.
Fam Hx: Mother aged thirty-one, living, hx of osteochondritis dissecans and hypertension. Father aged forty-eight, living, hx of lupus and diabetes. Maternal Grandma aged seventy-seven, deceased of myocardial infarction, hx of cva, and breast cancer. Maternal Grandpa aged seventy-eight, deceased of cva, hx of bone cancer and diabetes. Paternal grandma aged eighty-nine, deceased of lung cancer, hx of copd, and diabetes. Paternal grandpa aged ninety-six, deceased of brain and liver cancer, hx of lupus, and osteoarthritis. No siblings. Answer Discussion1
ROS:
GENERAL: Negative for fever, chills, and fatigue. Denies any light-headedness. Positive for sleep disturbances due to leg pain.
CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. No history of a heart murmur. Denies peripheral edema and claudication. Denies ECG testing in his lifespan.
RESPIRATORY: Denies shortness of breath, hemoptysis, cough, or sputum. Denies chest X-ray in his lifespan. Denies ever being tested for tuberculosis.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, and ataxia. Positive for numbness or tingling in the bilateral lower extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Positive for bilateral lower extremity muscle, joint pain, and stiffness. Negative for back pain. Positive for loss of range of motion in bilateral lower extremities. No history of arthritis or joint pain.
HEMATOLOGIC/LYMPHATICS: Denies anemia and bleeding. Positive for bruising easily. Denies swollen glands. No history of anemia. Denies previous blood transfusion. Denies history of splenectomy.
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Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.
VS: BP 135/88; P 90; RR 20; T 97.6; O2 96% on RA; Wt. 177lbs; Ht. 76”
GENERAL: Mr. Smith is a well-developed, well-nourished Caucasian male who is alert and cooperative. He is a good historian and answers questions appropriately. Patient appears anxious and diaphoretic.Answer Discussion1
CARDIOVASCULAR: Heart rate and rhythm regular. No murmurs, gallops, or rubs. No abdominal bruit auscultated. Distal pulses are 2+ symmetrical bilaterally. +2 dependent edema in bilateral lower extremities. Pain with palpation and range of motion testing.
RESPIRATORY: breath sounds are clear to auscultation in all lung fields. Chest wall expansion and diaphragmatic excursion symmetrical. No increased work of breathing.
NEUROLOGICAL: alert and oriented x4, cooperative. Mood is anxious with a flat affect. CN II- XII is grossly intact. Motor: upper 5/5; lower 4/5. Sensory intact to pinprick. DTRs 1+ bilateral lowers and symmetrical. DTRs 2+ bilateral uppers and symmetrical.
MUSCULOSKELETAL: partial weight bearing with left leg favoritism. Full ROM in bilateral upper extremities. Partial ROM in bilateral lower extremities. No scars were noted. Bilateral knee joint effusions were noted with edema. No clubbing or cyanosis was noted.
NECK: Supple, full range of motion. No thyromegaly. No carotid Bruits. A small Mass palpated behind the right ear approximately 2 cm in length and width: perfectly symmetrical. No tracheal deviation was noted. Cervical lymph node enlargement.
Diagnostic results: CBC with differential, CRP, Procalcitonin, Lactic acid, EKG, bilateral leg x-ray, bilateral leg ultrasound, antinuclear antibody tests, APTT/PT/INR, MRI of bilateral legs, and UA.
Each diagnostic test has a purpose. CBC w/Diff can evaluate for elevated WBC that could indicate leukemia or lymphoma. CRP can show inflammatory markers indicating disorders such as arthritic diseases and lupus. Procalcitonin can be an early indicator of infection-causing sepsis. Lactic acid can help rule out sepsis and bacterial infections that could be causing inflammation and joint pain (Woolnough et al., 2021). EKG is needed due to this patient never had a baseline test done. Bilateral knee X-ray to rule out anything broken or displaced. Bilateral Leg ultrasound to rule out any potential DVTs causing the pain and swelling. ANA testing can rule out lupus (Jin et al., 2021). APTT/PT/INR to rule out the potential for clotting or bleeding since the patient bruises easily. UA to help get a general idea of kidney function and if there is a possibility for an infection. An increased protein level or red blood cells in the urine could also indicate an infection such as lupus has affected your kidneys. MRI can assess for damage to the hard and soft tissues of the legs.
A. Differential Diagnoses (list a minimum of three differential diagnoses).
1. Osteochondritis: due to the joint pain that started and progressed over time. An injury such as a horse-drawn buggy accident could have been the trauma that the weakened bone needed to cause loose bodies to break off into the tissues causing the joint to “click” or “lock up” randomly (Osteochondritis Dissecans | Boston Children’s Hospital, n.d.).
2. Juvenile arthritis: with the patient’s signs and symptoms this diagnosis can be determined using a CRP blood test and x-ray. Most of the juvenile arthritis cases have an unknown etiology but have been studied as a possible autoimmune disease (Woolnough et al., 2021).
3. Torn Meniscus: with swelling and joint pain paired with the buggy races. History of a wreck with trauma that was untreated makes this a possibility. An MRI of the bilateral lower extremities can rule this out (Agarwal, 2021).
4. Chondromalacia patella: can manifest as pain in the knee and thigh bone. Dull aching pain and a feeling of grinding can be felt. This can also be testing using an MRI and Blood tests to rule out blood disorders (Woolnough et al., 2021). Answer Discussion1
5. Lupus: Lupus is on here due to the strong genetic possibility. Blood testing such as the inflammatory markers and the ANA testing can help diagnose lupus (Alvarex et al., 2022).
References
Agarwal, A. (2021). Examination of Knee Joint in a Child. In Clinical Orthopedic Examination of a Child (pp. 119-137). CRC Press.
Álvarez, P. M., Bracaglia, C., Messia, V., Caiello, I., De Benedetti, F., & Marasco, E. (2022). PO. 2.31 Different patterns of longitudinal changes in antinuclear antibodies titres in children with systemic lupus erythematosus.
Jin, W., Yang, X., & Lu, M. (2021). Juvenile-onset multifocal osteonecrosis in systemic lupus erythematosus: A case report. Medicine, 100(2), e24031. https://doi.org/10.1097/MD.0000000000024031
Osteochondritis Dissecans | Boston Children’s Hospital. (n.d.). Retrieved October 18, 2022, from Answer Discussion1 https://www.childrenshospital.org/conditions/osteochondritis-dissecans
Woolnough, L., Pomputius, A., & Vincent, H. K. (2021, March). Juvenile idiopathic arthritis, gait characteristics and relation to function. Gait &Amp; Posture, 85, 38–54. https://doi.org/10.1016/j.gaitpost.2020.12.010