NURS 6512 Week 9: Assessment of Cognition and the Neurologic System Week 9: Assessment of Cognition and the Neurologic System

NURS 6512 Week 9: Assessment of Cognition and the Neurologic System Week 9: Assessment of Cognition and the Neurologic System

Patient Information: Case #3.

Patient Initials: T.P                 Age: 15           Gender: Male.

SUBJECTIVE: 

Chief Complaint (CC): Knee Pain

History of Present Illness (HPI): The patient who initials is T.P is a 15-year hold make that was presented to the clinic, reports that the pain he feels in one and at times both of his knees started 5 days ago. T.P also informs that he will always experience a catching sensation whenever one or both of this knees click, the catching sensation is felt under the patella. T.P also informs that the pain does not go away immediately, and whenever he stands for quite some time, it makes the pain even worse.  Also, T.P reported that he is often feeling a constant form of pain, and prolonged running or standing will also make it worse. T.P also informed the clinician that he once twisted his knees while he was playing football five days ago.  Also, the patient stated that the has not been able to play with his hockey team due to the pain he feels. T.P also reports that since the injury he has been forced to wear a knee bracelet whenever the pain becomes unbearable. At times the patient reports he has had to use painkillers like ibuprofen, which unfortunately only drives the pain away temporarily. T.P reports that to a scale of 1-10 the pain level is at 6/10

Medications: Patient takes daily Multivitamin

Allergies: Penicillin.

Past Medical History (PMH): Patient reports seasonal allergies.

Past Surgical History (PSH): None.

Immunization History: Flu shot which was received this season.

Significant Family History: Patient reports that his maternal grandmother suffers from osteoarthritis.

SOCIAL HISTORY: Patient has been able to attend school regularly, he also plays hockey with his high school team. Patient does not smoke, does not take alcohol and does not partake any illicit drug.

REVIEW OF SYSTEMS:  

General: No Chills, fever or report of fatigue.

Neck: No injury, pain or history of disc compression or disc disease.

Musculoskeletal: No evidence of arthritis, gout.  Patient reports limited range of motion through the affected knees. Patient has not history of fractures or trauma.

Allergic/Immunologic: Seasonal allergic rhinitis.

OBJECTIVE

PHYSICAL EXAM:

Vita/l signs: B/P — 110/64, P — 75, T — 97.8, RR — 20, Wt — 166 lbs., Ht — 5’10”, BMI — 23.7.

General: The patient is very oriented and Alert x4, there is no evidence of distress.

Neck: No Pain, No JVD present, trauma, rigidity or injury. Trachea is midline. Patient exhibits normal range of motion.

Musculoskeletal: There is evidence of symmetric muscle development, the muscle strengths 5/5 all groups. Patient’s knees appear swollen, they are also tender to touch. Limited range of motion in both knees. There is an audible click heard when patient performs the McMurray maneuver.

Neuro: CNII-XII grossly intact, deep tendon reflexes intact.

Diagnostic tests: ESR, CBC, MRI, Radiography.

ASSESSMENT

Differential Diagnosis:                            

Patellar Tendinitis (jumpers’ knee)

Osteoarthritis

Medial Meniscus Tear

ACL tear

Medial Collateral Ligament Sprain

Justification of Diagnostic Tests and Differential Diagnosis

People of an adolescent age they are usually very playful and will engage in various sports that would easily result to conditions such as the Knee pain injury. The diagnostic tests are important as they ensure that there is accuracy in the Knee pain diagnosis including ESR and CBC, MRI and Radiography. In this case, a CBC is important as it is going to reveal whether there is presence of anemia, which would mean the patient suffers from a chronic condition. It would also reveal various alterations to White Blood cell count that co