RUNNING HEAD: SOA Note.

Musculoskeletal

SOA Note Musculoskeletal

N5644 Advanced Health Assessment and Differential Diagnoses

SOA Note. Musculoskeletal

SOA Note Musculoskeletal Subjective Identifying Criteria: A.A. is a 50 year old African American male retail store manager presenting to the clinic on 07/25/2011. No other family members or friends are present during the exam. Date of birth: 07/16/1961. Marital status: Married. Clinic: Total Care Family Clinic, Fairland, BX 77333. Insurer: Humana Chief Complaint: In quotes, i.e., patients own words: My right knee joint aches. It feels stiff sometimes. History of Present Illness: A.A. presented to the clinic because he has been experiencing pain to his right knee for the past four weeks. He states pain started gradually but does not radiate. He describes pain as aching. Pain is intermittent and lasts for 10-15 minutes. Rates pain at five out of ten on the pain scale. He reports that pain occurs early in the morning most times and after standing or bending for a long period of time. When severe, especially in the morning, it takes him time to get out of bed and start activities for the day. Pain eases with activity in the mornings and sometimes rest when at work. He has not taken any pain medication for relief. He denies fever, chills, weight loss, chest pain, shortness of breath, constipation or renal problems. Past Medical History: Allergies: No known drug food or environmental allergies.

SOA Note. Musculoskeletal

Current Medications: He denies taking any medications at present. Denies use of any alternative medications. Previous health care: Last health maintenance exam & EKG 09/2010 with normal findings. Last dental exam was 2 years ago. Has never had visual screening. Received all childhood immunizations including measles, mumps, rubella, DTap, Polio and Varicella (immunity by disease). DTap booster in 2010, flu vaccine 10/2010, Hepatitis B series complete. Tetanus shot in 1992. Last Tuberculosis test was negative on 02/2011. Has never has pneumonia vaccine. No recent lab results reported. Illnesses and injuries: Varicella, mumps and measles at 8years. No other major childhood or adult illnesses. Denies seasonal allergies. Denies injuries, accidents or hospitalizations. Denies blood transfusions in the past. Denies any sexual problems or history of sexually transmitted diseases. Family History: A.A. is an only child. Father is 72 years, alive with a history of hypertension and diabetes. Mother is 69 years, alive with a history of hypertension. Paternal and maternal grandparents are deceased. Their health history and cause of death are unknown to pt. Denies family history of smoking, alcohol use, stroke, cancer, liver disease, renal disease or thyroid disorder. Pt has a son, age 21, alive and well. Social History/Health Promotion: Pt is currently employed and has been working as a store manager for six years at the grocery store in his neighborhood. He is married with a son, age 21. Lives with his wife in a single family home in a quiet neighborhood. His son is a full time student and lives on campus. He comes home during holidays. No extended family member lives around. His wife is an elementary school teacher. He reports feeling financially stable with no

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economic concerns. He enjoys reading newspapers at his leisure. He has never travelled out of the United States and has never been exposed to any disease or illness. He has not been around any sick person recently. Drinks 2-3cups of coffee and a can of coca cola daily. Denies use of alcohol, cigarettes, illicit drugs, herbs or complementary medicine. Eats breakfast and dinner daily at home and lunch at work. Diet consists mainly of carbohydrates and meat products. Reports minimal intake of vegetables and fruits. Engages in no formal exercise regimen but walks around the neighborhood with his wife two days every week. He is sexually active with his wife only and practices safe sex with condoms. He sleeps about six hours at night. Takes occasional naps during the day when hes not at work. Denies any religious affiliation. Personal safety at home: He uses seat belt consistently. Does not use sunscreen. All the rooms in his house have functioning smoke and CO2 detectors. All medications are locked in a kitchen cabinet. Cleaning and toxic substances are kept in an unlocked shelf in the laundry room. Review of Systems: General: Stated weight 265lbs. Denies fatigue, fever, chills, night sweats, unintentional weight gain or loss. Skin: Denies rashes, lumps, sores, itching, dryness, change in color and change in appearance of hair or nails. Denies change in size or color of moles. Head/Eyes/Ears/Nose/Throat: Denies trauma, migraines or scalp tenderness. Denies double or blurred vision, spots, specks, pain, redness or tearing of eyes. Denies difficulty hearing, tinnitus, vertigo, or ear discharge. Denies frequent colds, nasal stuffiness, discharge, itching, nose bleeds or sinus trouble.

SOA Note. Musculoskeletal

Respiratory: Denies cough, shortness of breath, dyspnea. Denies sputum, wheezing, asthma, bronchitis, emphysema, pneumonia or tuberculosis. Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations, heart murmurs, dyspnea or orthopnea. Denies numbness or tingling in lower extremities. Gastrointestinal: Denies vomiting, diarrhea, constipation or change in bowel habit. Last bowel movement 07/25/2011. Denies swallowing difficulty, heartburn or change in appetite. Genitourinary: Denies urinary urgency, frequency or blood in urine. Denies penile discharge or soreness. Denies any history of sexually transmitted disease (STD). Musculoskeletal: Reports acing pain, stiffness and limited range of motion to right knee usually in the morning. States pain also occurs with repeated bending and standing for a long time at work. Reports stiffness lasts for 10-15minutes. Denies redness or swelling. Reports full range of motion to other joints (upper and lower extremities). Neurologic: Denies change in orientation, memory, judgment, attention or speech. Denies headache, blurred vision, dizziness, vertigo, seizures, tremors or involuntary movement. Psychiatric: Denies depression. Denies sudden mood changes, anxiety, irritability, panic attacks or suicidal thoughts. Objective Data General: Alert and oriented to person, place, time and situation. Obese. Well groomed but appears tired. Maintains eye contact. In no apparent distress. Vital Signs: Temp: 97.6F (oral), HR: 88bpm and regular RR: 20,

SOA Note. Musculoskeletal

BP: 130/73(right arm, sitting), Pain-5/10, Ht: 5ft 7in,

O2 sat: 99% on room air,

Wt-265.2lbs, BMI-37.0

Skin: Warm and dry. No lesions, sores, redness or rashes present. Elastic turgor. Normal hair texture with receding hairline. No nail clubbing or cyanosis. Cardiovascular/Peripheral Vascular: Regular rate and rhythm. S1S2 normal. No extra heart sound. Radial, carotid, femoral, dorsalis pedis, posterior tibial pulses present and 2+ bilaterally. Capillary refill <3secs. No edema to bilateral extremities. No cyanosis. No abdominal or femoral bruits noted. Gastrointestinal: Abdomen soft, round, non-distended, non-tender. Bowel sounds present to all quadrants. No tenderness to light and deep palpation. No palpable masses. Musculoskeletal: Normal gait. Limited range of motion noted to right knee. Slight swelling noted to right knee. Positive bulge sign, negative balloon sign. Balloting of patella negative for large effusion. No spine deviation. No abnormal gait, joint deformity or instability. Psychiatric: Normal body posture. Speech clear and coordinated. Normal affect. Diagnostic Tests:

Bulge sign, balloon sign and balloting the patella Radiographs, MRI Arthroscopy of knee

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Assessment Differential Diagnoses:

1. Fibromyalgia: The main symptom of fibromyalgia is diffuse musculoskeletal pain and

tenderness which may occur in joints, muscles, tendons and other soft tissues (Bickley, 2009). In fibromyalgia, stiffness occurs early in the morning but there is no limitation in range of motion and there is no swelling (Bickley, 2009). There is also sleep disturbance associated with morning fatigue (Bickley, 2009). On physical exam, examiner will usually find hyperalgesic tender sites and medial fat pad of knee (Seller, 2007). People with fibromyalgia tend to wake up with body aches and stiffness which may or may not improve during the day (Makeover, 2011). At present, there is no gold standard for diagnosing fibromyalgia (Bennett, 2009). Based on physical findings, A.A. most likely does not have fibromyalgia.
2. Rheumatoid arthritis: The primary characteristic of rheumatoid arthritis is the chronic

inflammation of synovial membranes (Bickley, 2009). Secondary to inflammation is the erosion of adjacent cartilage and bone as well as damage to ligaments and tendons (Bickley, 2009). Clinical findings show swelling of synovial tissue in joints and subcutaneous nodules (Bickley, 2009). Stiffness is often for an hour or more in the morning and after inactivity (Bickley, 2009). Weakness, fatigue, low grade fever and weight loss are common (Bickley, 2009). A.A. most likely does not have rheumatoid arthritis because (a) stiffness lasts only 10-15minutes at a time (b) he denies fever or weight loss (c) symptoms have lasted for only four weeks.

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3. Osteoarthritis: ICD 9 code: 714.0 Concluding Diagnosis: This is the gradual

degeneration and progressive loss of cartilage within the joints (Bickley, 2009). It progresses slowly with temporary exacerbation after periods of overuse (Bickley, 2009). There is frequent, brief stiffness of joints which usually lasts 5-10 minutes (Bickley, 2009). Limited range of motion is common with small effusions to the affected joint as well as bony enlargement (Bickley, 2009). Fever, fatigue, weight loss and other generalized symptoms are usually absent (Bickley, 2009). Radiographs are considered the gold standard test for diagnosing osteoarthritis (Ling & Bathon, n.d.). A.A. most likely has osteoarthritis because his symptoms are consistent with expected clinical findings. He states that his pain lasts for only 10-15mins at a time and has lasted for about four weeks. Bulge sign was positive which indicates presence of minor effusions (Bickley, 2009). His history of obesity, age and the nature of his job are also major risk factors for osteoarthritis. These are essential information which aids practitioner to successfully determine the most likely diagnosis of osteoarthritis. Nursing Diagnosis: Acute pain related to joint inflammation. Health or Injury Risk Factors:

Obesity Joint overuse: Pt has a job that requires repeated bending of the knee. Age: People over 40years are at higher risk for osteoarthritis (Seller, 2007).

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References Bennett, R.M. (2009). Clinical manifestations and diagnosis of fibromyalgia. Rhematic disease clinics of North America 35(2), 215-232. Bickley, L.S. (2009). Bates guide to physical examinations and history taking (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins Ling, S.M., & Bathon, J.M. (n.d.). Osteoarthritis: Clinical presentations. Retrieved from http://www.hopkins-arthritis.org/arthritis-info/osteoarthritis/clinical-presentation.html Makeover, 2011, February 14. Fibromyalgia. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmedhealth/PMH0001463/ Seller, R.H. (2007). Differential diagnosis of common complaints (5th ed.). Philadelphia, PA: Saunders & Elsevier