DISCUSSION 1 Case 1: Back Pain A 42-year-old male reports pain in his lower back for the past month. The pain sometimes radiates to his left leg. In determining the cause of the back pain, based on your knowledge of anatomy, what nerve roots might be involved? How would you test for each of them? What other symptoms need to be explored? What are your differential diagnoses for acute low back pain? Consider the possible origins using the Agency for Healthcare Research and Quality (AHRQ) guidelines as a framework. What physical examination will you perform? What special maneuvers will you perform? Patient Information: M.S. Age 42 Caucasian Male S. CC : “Lower Back Pain” HPI : The patient is a 42-year-old white male who developed lower back pain for 1 month. He states the pain radiates to his left leg. His lower back pain is increased with sitting for long periods of time, states the pain gets better when stands and with some Tylenol.  Denies any fever, chills, and sweating. Current Medications : Tylenol 200 mg two every 4 to 6 hours as needed for pain. Allergies: No known drug, food, or environmental allergies. PMHx : None Up to date on all immunizations, received flu shot this year. Last tetanus shot 1 years ago.  PSHx: none Soc Hx :  M.S. is a retired plumber who lives alone. He enjoys activity such as walking, bike riding and camping outdoors. Nonsmoker, social drinker 3-4 beers on the weekends, denies illegal drug use. Personal/Social History: Patient denies ever smoking cigarette. Denies any recreational drug use. Fam Hx : Mother alive, age 72-years-old, breast cancer at age 52 in remission. Father died at age 70 (2yrs ago) – history of CAD, MI age 70 died.  Maternal grandmother: Hypertension, breast cancer. Maternal grandfather: Hypertension, BPH, GERD, atrial fibrillation, hyperlipidemia, CHF, AICD. Paternal grandmother: Unknown history Paternal grandfather: Hypertension, CKD, GERD, BPH, COPD, asthma. ROS : GENERAL:  No weight loss. Complaint of lower back pain. No complaint of fever, chills, weakness, fatigue, constipation, bladder, or bowel incontinent. HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN:  No rash or itching. CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY:  No Complaint of sob, no cough. GASTROINTESTINAL:   No anorexia, nausea, vomiting or diarrhea. No abdominal pain or bowel incontinent, no rectal pain or bleeding GENITOURINARY:  No difficulty with urination, no urinary leakage or incontinence. NEUROLOGICAL:  No headache, no dizziness, no syncope, no paralysis, no ataxia, no numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: complaints of lower back pain radiate to back of right leg. Pain 8/10, sometimes increase pain when turning in bed, walks with limp when having pai.

1. DISCUSSION 1
Case 1: Back Pain
A 42-year-old male reports pain in his lower back for the past
month. The pain sometimes radiates to his left leg. In
determining the cause of the back pain, based on your
knowledge of anatomy, what nerve roots might be involved?
How would you test for each of them? What other symptoms
need to be explored? What are your differential diagnoses for
acute low back pain? Consider the possible origins using the
Agency for Healthcare Research and Quality (AHRQ) guidelines
as a framework. What physical examination will you perform?
What special maneuvers will you perform?
Patient Information:
M.S. Age 42 Caucasian Male
S.
CC
: “Lower Back Pain”
HPI
: The patient is a 42-year-old white male who developed lower
back pain for 1 month. He states the pain radiates to his left leg.
His lower back pain is increased with sitting for long periods of
time, states the pain gets better when stands and with some
Tylenol. Denies any fever, chills, and sweating.
Current Medications
: Tylenol 200 mg two every 4 to 6 hours as needed for pain.
Allergies:

2. No known drug, food, or environmental allergies.
PMHx
: None Up to date on all immunizations, received flu shot this
year. Last tetanus shot 1 years ago.
PSHx:
none
Soc Hx
: M.S. is a retired plumber who lives alone. He enjoys activity
such as walking, bike riding and camping outdoors. Nonsmoker,
social drinker 3-4 beers on the weekends, denies illegal drug
use.
Personal/Social History:
Patient denies ever smoking cigarette. Denies any recreational
drug use.
Fam Hx
: Mother alive, age 72-years-old, breast cancer at age 52 in
remission. Father died at age 70 (2yrs ago) – history of CAD,
MI age 70 died. Maternal grandmother: Hypertension, breast
cancer. Maternal grandfather: Hypertension, BPH, GERD, atrial
fibrillation, hyperlipidemia, CHF, AICD. Paternal grandmother:
Unknown history
Paternal grandfather: Hypertension, CKD, GERD, BPH, COPD,
asthma.
ROS
:
GENERAL: No weight loss. Complaint of lower back pain. No
complaint of fever, chills, weakness, fatigue, constipation,
bladder, or bowel incontinent.

3. HEENT: Eyes: No visual loss, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema.
RESPIRATORY: No Complaint of sob, no cough.
GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or bowel incontinent, no rectal
pain or bleeding
GENITOURINARY: No difficulty with urination, no urinary
leakage or incontinence.
NEUROLOGICAL: No headache, no dizziness, no syncope, no
paralysis, no ataxia, no numbness or tingling in the extremities.
No change in bowel or bladder control.
MUSCULOSKELETAL: complaints of lower back pain radiate
to back of right leg. Pain 8/10, sometimes increase pain when
turning in bed, walks with limp when having pain. Patient
reports a lower back for one-month, intermittent pain when
ambulating that shoots down the right, lateral thigh, down to the
knee, and no numbness of leg. The patient states his pain is
relieved somewhat with his OTC Tylenol. Patient denies any
swelling, redness, or heat at any of the joint sites.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes in the groin. No history of
splenectomy.

4. PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No complaints of fever, chills, and
sweating.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam
:
VS
: BP 140/76; P 82; R 19; T 97.7F; O2 SAT 99%; Wt. 200 lbs.;
Ht 6’8”, pain 8/10 on scale of 0-10 at rest
General:
42-yr-old Patient presents as a well-developed, young adult
Caucasian who appears his stated age. He is alert, oriented, and
cooperative. The patient walks with slight limp,
HEENT
: normocephalic head with normal distribution of hair. No facial
tenderness to light sensation. Conjunctivae are pink with white
sclera and without jaundice. PERLA, with pupils 3mm in size
bilaterally. No exudates seen. Nasopharynx and pharynx without
erythema, lesions, or exudates. Mucous membranes are moist.
Upper and lower teeth in good condition and intact. The trachea
is midline.
Neck
: normal ROM, Supple with no JVD or bruits, there is no
adenopathy. No swelling noted.
Chest/Lungs:

5. Lungs are clear to auscultation anteriorly and posteriorly with
equal symmetry of chest rise and fall. Resonance noted to
percussion bilaterally. No wheezes, rhonchi or stridor.
Cardiovascular
: RRR without murmur. Good S1, S2. Radial and pedal pulses
+2 bilaterally. No abdominal, carotid, or femoral bruits. No
JVD.
Peripheral vascular
: No edema of extremities. 2+ palpable radial, posterior tibial,
and dorsalis pedis pulses. Normal distribution of hair on lower
extremities. Normal color. Capillary refill less than 3 seconds.
No cyanosis or clubbing present.
Abdomen:
Flat, soft NABS x4. non-tender, no inguinal nodes noted.
Genital/Rectal:
Deferred.
Musculoskeletal:
Symmetrical development of upper and lower extremity. No
erythema or deformities of joints. Palpate pain noted at the right
lower lumbar region. Pain to lower back when leg is extended
while thigh if flexed when lying flat. Limited ROM of right leg
with pain at 40 degrees when lifting. ROM limited to forward
bending 10 inches from the floor. Pain to right buttock area and
right posterior thigh with palpation. Minimal flexion of the
right knee due to pain. No crepitus or stiffness to palpitation of
joints. Other joints unremarkable.
Neurological:
CN II-XII intact. DTRs 2+ lower extremity intact. Sensory
neurology intact to light touch and patient able to toe and heel
walk. Normal gait with ambulation and limping noted.

6. Skin:
Warm and dry to touch. No ecchymosis or edema. No noted
rashes, open wounds, or lesions. Hair is evenly distributed over
scalp.
Diagnostic tests/labs:
a. Walk across the room to examine abnormalities in patient gait
(pattern of walking)
b. Hip flexion and knee hyperextension up to 30 degrees. Bend
or flex parts of your spine to assess spinal range of motion
example bend forward)
c. Simply stand to identify any problems with balance, posture
and/ spinal alignment
d. The femoral stretch test is used to detect inflammation of the
nerve root at the L1, L2, L3 and L4
e. CBC: used to confirm the diagnosis of infection.
f. Urinalysis to check for UTI.
g. XR lumbar spine
h. Plain-film X-ray provides 2 view of motion and evidence of
trauma.
i. CT scanning: Detect abnormal tissue and the state of the
patient’s spine.
j. MRI Lumbar spine: used to generate detailed images or slices
of the spinal anatomy. MRI also can reveal the structure of soft
tissues, such as the discs, spinal cord, and nerves. (Dains, J. E.,

7. Baumann, L. C., & Scheibel, P., 2016).
A
.
Differential Diagnoses:
1. Lumbosacral Herniated Disc
2. Cauda Equina
3. Musculoskeletal Lumbar Strain
4. Acute Pyelonephritis,
5. Lumbar spinal stenosis
Lumbosacral Herniated Disc
is the most appropriate diagnosis. The authors Kim et al., 2018,
stated that “one person from eight suffers from degenerative
disc disease, as well as from various joint diseases (arthrosis,
arthritis, sciatica), the pain being in the medial or inferior part
of the spine. At first, it is manifested as a slight redness, then
pain occurs when walking or bending, and then gradually
radiating to the leg, which can affect the individual life” (Kim
et al.,2018). And my patient is exhibiting these symptoms.
Lumbosacral Herniated Disc (Sciatica):
According to Ball et al., 2015 Herniated disc disease usually
caused by degenerative changes in the disc. The most common
sources of back pain are abnormally changed discs, facet and
sacroiliac joints, and muscles; however, it is often difficult to
determine the main source of pain. The nerve root generally
involves occurs at L4, L5 and S1 nerve roots. This patient is at
greater risk because of his age group and may involve trauma
because this patient occupation as a plumber.

8. According to Koes, Van-Tulder and Peul 2007 “other symptoms
that need to be explored are unilateral leg pain greater than low
back pain, Pain radiating to foot or toes, numbness and
paranesthesia in the same distribution, straight leg raising test
induces more leg pain, localized neurology changes that
involves L4, L5 and S1 that which is to limit one nerve root”
(Koes., van Tulder., & Peul, 2007).
Cauda Equina:
According to Dains, Baumann and Scheibel 2016, “Cauda
Equina compression of S1 nerve root produce continuous lower
back pain with saddle distribution of anesthesia. The patient
will present with symptom include lower back pain, unilateral
or bilateral sciatica nerve pain, bowel, and bladder disturbances
generally present with BB incontinence, lower extremity motor
weakness with limping, sensory losses or deficits in the lower
extremity and reduced or absent lower extremity reflexes”
(Dains, J. Baumann, L. & Scheibel, P. 2016). I choose it
because my patient is presenting with some of the symptoms.
Musculoskeletal Lumbar Strain:
Lumbar strain is based on history and clinical findings. A
complete history may suggest the cause of acute lower back
pain based on the type of injury the patient sustained (Lupu.,
A.,2017). If the patient present with no history of trauma or no
history of strenuous physical activities, then the likely
diagnosis of Lumbar strain is evident. According to Dains,
Baumann and Scheibel 2016 “muscles in the back can become
inflamed from over usage of muscles and ligaments. Patient
report that rest will alleviate pain and with treatment of heat or
cold therapy” (Dains, J. E., Baumann, L. C., & Scheibel, P.,
2016).
Acute Pyelonephritis:
The range of acute pyelonephritis is wide, from a mild illness to

9. sepsis. According to Dains, Baumann and Scheibel 2016,
“patients may appear very ill and diaphoretic with symptoms of
nausea, vomiting, headache, and back or flank pain” (Dains, J.
E., Baumann, L. C., & Scheibel, P., 2016). To diagnose acute
pyelonephritis, the practitioner must rely on evidence of UTI
from urinalysis or culture, along with signs and symptoms
suggesting upper UTI (fever, chills, flank pain
,
nausea, vomiting, costovertebral angle tenderness). Symptoms
that are suggestive of cystitis (dysuria, urinary bladder
frequency and urgency, and suprapubic pain) also may be
present.
Lumbar spinal stenosis
- Lumbar spinal stenosis (LSS) is a disease in which
degenerated discs, ligamentum flavum, facet joints, while aging,
lead to a narrowing of the space around the neurovascular
structures of the spine (Fishchenko et al., 2018). Symptoms may
be due to inflammation or compression of the nerve and include
pain and weakness or numbness in the legs. There is no ‘gold
standard’ for diagnosis of LSS; the diagnosis is based on a
combination of factors including history, physical examination,
and imaging studies. Assessment should focus on leg or buttock
pain while walking, flex forward to relieve symptoms, feel
relief when using a shopping cart or a bicycle, motor or sensory
disturbance while walking, pulses in the foot present and
symmetric, and lower extremity weakness (Chagnas et al.,
2019). Imagining can be used to determine if there is any
inflammation, and when surgery is becoming imminent.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015). Seidel's guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby.

10. Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced
health assessment and clinical diagnosis in primary care (5th
ed.). St. Louis, MO: Elsevier Mosby.
Koes, B. W., van Tulder, M. W., & Peul, W. C. (2007).
Diagnosis and treatment of sciatica. BMJ: British Medical
Journal, 334(7607), 1313–1317.
http://doi.org/10.1136/bmj.39223.428495.BE
Jung-Ha Kim, Rogier M. van Rijn, Maurits W. van Tulder, Bart
W. Koes, Michiel R. de Boer, Abida Z. Ginai, Arianne P.
Verhagen. (2018). Diagnostic accuracy of diagnostic imaging
for lumbar disc herniation in adults with low back pain or
sciatica is unknown, a systematic review.
Chiropractic & Manual Therapies, Vol 26, Iss 1, Pp 1-14 (2018)
, (1), 1. https://doi-org.ezp.waldenulibrary.org/10.1186/s12998-
018-0207-x
Lupu., A., (2017). Diagnosis and treatment difficulties in the
case of a patient with Chronic Low Back Pain. Balneo Research
Journal, Vol 8, Iss 4, Pp 248-251 (2017), (4), 248. https://doi-
org.ezp.waldenulibrary.org/10.12680/balneo.2017.160
Discussion 2
Chi
NURS 6512: Advanced Health Assessment and Diagnostic
Reasoning INITIAL POST
Case Study #3
Patient Initials: _SC__ Age: __15___ Gender: _M__

11. SUBJECTIVE DATA:
Chief Complaint (CC): A dull pain in both knees with
occasional clicking in one or both knees and the sensation of the
patella catching.
History of Present Illness (HPI): SC is a 15-year-old male who
reports dull pain in both knees. Sometimes one or both knees
click, and the patient describes a catching sensation under the
patella. He states that the pain has been on and off for the last
four months and initially only present after intense activity but
has gotten worse since starting track this summer and seems to
be present more often than before. The patient states that the
clicking comes and goes and isn’t always present in both knees
at the same time. The catching sensation under the patella is
more pronounced since he started doing the long jump in track.
The patient states that he is able to bear weight as the pain is a
dull ache. Icing his knees after sports and taking ibuprofen help
reduce the pain and swelling but both occur more frequently
now making it difficult to participate in sports. The patient feels
that maybe he is over doing it with all of the sports he
participates in and is worried about not being able to pay soccer
if it continues to get worse. The patient rates the pain 7/10 after
extreme activity.
Medications:
Ibuprofen 200 mg oral tab, two tabs every 6 hours as needed for
pain.
Allergies: No known drug, food, or environmental allergies.
Past Medical History (PMH): None

12. Past Surgical History (PSH): None
Sexual/Reproductive History: Patient is not sexually active at
this time.
Personal/Social History: Patient denies smoking, alcohol use,
and illicit drug use. The patient is very active with sports
playing soccer, basketball and track. He states that he tries to
eats well particularly because of sports but doesn’t always make
the best choices for snacks. He tries to avoid soda most of the
time and does drink a lot of water.
Immunization History: Immunizations are up to date. Gets the
flu vaccine routinely every year.
Significant Family History:Paternal grandmother has
hypertension. Father has borderline hypertension. Maternal
grandmother has type II diabetes. Lifestyle: SC is a freshman in
high school who lives with both of his parents and 2 younger
siblings, a brother and sister. SC plays soccer, basketball and
participates in track for high school. SC also plays club soccer
playing most of the year. SC is a good student who is very
athletic and enjoys being active. He also participates in winter
sports and skis almost every weekend during the winter months.
He only works part-time during the summers due to his
commitment to school and sports.
Review of Systems:
General: No recent weight gain or loss of significance. Patient
denies fatigue, fever, or chills.
HEENT: No headaches or dizziness. No changes in vision. He
does not wear glasses and his last eye exam was just under a
year ago. Denies eye drainage, pain, or double vision. No
changes in hearing. Has had no recent ear infections, tinnitus or

13. ringing in the ears. Denies sinus infections, congestion, and
epistaxis. He reports his sense of small is intact. Last dental
exam 3 weeks ago for regular cleaning. Denies bleeding gums
or toothache. Denies dysphagia or throat pain. Neck: No history
of trauma, denies recent injury or pain. He denies neck
stiffness.
Breasts: Denies any breast changes. Denies of history rashes.
Denies history of masses or pain.
Respiratory: Denies cough, hemoptysis, and sputum production.
Patient denies any shortness of breath with resting or with
exertion. Patient reports no pain with inspiration or expiration.
Cardiovascular/Peripheral Vascular: No history of murmur or
chest palpitations. No edema or claudication. Denies chest pain.
No history of arrhythmias. Last bowel movement was this
morning. Denies rectal pain or bleeding. Denies changes in
bowel habits. Denies history of dyspepsia.
Genitourinary: Denies changes in urinary pattern. No
incontinence, no history of STDs or HPV, patient is
heterosexual and not sexually active. Denies hematuria. Denies
urgency, frequency, and dysuria.
Musculoskeletal: No limitation in range of motion for all limbs
though patient reports difficulty moving knees after excessive
strain from sports. No history of trauma or fractures. Patient
reports dull pain in both knees. Patient states occasional
swelling in knee joints after participating in sports. Patient
reports clicking in one knee and sometimes both. Patient states
that the pain is worse after participating in the long jump or
running longer distances. Patient denies history or presence of
misalignment of either knee.
Psychiatric: Denies suicidal or homicidal history. No mental

14. health history. Denies anxiety and depression.
Neurological: No dizziness. No problems with coordination.
Denies falls or seizures. Denies numbness or tingling. Denies
changes in memory or thinking patterns.Skin: No history of skin
cancer. Denies any new rashes or sores. Patient reports
occasional plantar warts which he has treated with compound
W. Denies eczema and psoriasis. Denies itching or swelling.
Hematologic: No bleeding disorders or history of blood
transfusion. Denies excessive bruising.
Endocrine: Patient reports no endocrine symptoms.Denies
polyuria, polydipsia. Patient denies no intolerance to heat or
cold. Allergic/Immunologic: Denies environmental, food, or
drug allergies. No known immune deficiencies.
OBJECTIVE DATA:
Physical Exam: Vital signs: B/P 122/80; P 70 and regular; T
98.6; RR 16; O2 100% on room air; Wt: 122 lbs.; Ht: 5’7”; BMI
19.1
General: SC is a well-developed, well-nourished Caucasian
teenage male who appears to be in no apparent distress.
HEENT: Head: Skull is normocephalic, atraumatic. No masses
or lesions. Eyes: PERRLA, +direct and consensual pupil
response. EOM intact, 20/20 vision bilaterally without
correction. Fundoscopic exam normal, vessels intact, optic disc
with clear margins. Ears: Bilateral external ears no lesions,
masses, drainage or tenderness. Tympanic membranes intact,
pearly gray, no bulging, no erythema, and landmarks
appreciated bilaterally. Hearing intact bilaterally. Nose: No
nasal flaring, no discharge, no obstruction, septum not deviated.
Turbinates pink and moist. No polyps or lesions bilaterally.

15. Nares patent with no edema or erythema. Throat: Oropharynx
clear and mucosa moist. No erythema or exudate. Uvula
midline, palate rises symmetrically.Mouth: No lesions, no
thrush. Moist mucous membranes. Healthy dentition present.
Tongue midline. Neck: Supple, non-tender. Full range of
motion. Trachea midline. No masses. Thyroid and lymph nodes
not palpable.
Chest/Lungs: Thorax non-tender with symmetric expansion.
Respiration regular and unlabored, without cough. Tactile
fremitus equal bilaterally and greater in upper lung fields.
Breath sounds clear with adventitious sounds. All lung fields
with resonant percussion tones.
Heart: Regular rate and rhythm; normal S1, S2; no murmurs,
rubs, or gallops. Apical pulse not visible. Apical pulse barely
palpable. JVP appears to be approximately less than 6 cm with
HOB elevated to 45 degrees. No carotid bruits or JVD
appreciated. Peripheral Vascular: Pulses 2+ bilateral pedal and
2+ radial bilaterally. No pedal edema. Popliteal pulses 2+
bilaterally.
Abdomen: Abdomen round, soft, and non-tender without rash,
palpable mass or organomegaly. Active bowel sounds. Tympany
over most quadrants with scattered areas of dullness noted upon
percussion. No abdominal bruits.
Genital/Rectal: Adequate tone, no masses noted, eXternal
genitalia intact.
Musculoskeletal: Normal passive and active ROM in upper and
lower extremities. No focal joint inflammation or abnormalities
appreciated in upper extremities. + tenderness to palpation at
the inferior pole of the patella bilaterally. + Q angle greater
than 10 degrees bilaterally. Clicking present with movement in
right knee. Normal alignment of the knees bilaterally. All upper

16. and lower extremity joints without effusions or erythema. Spine
without tenderness and range of motion is full. Greater
tenderness was noted in knees bilaterally when extended and
quadriceps are relaxed. Normal muscle strength present against
resistance.
Neurological: CN ll-Xll grossly intact. Awake, alert, and
oriented to person, place and time. Patient can move all limbs
on command and spontaneously.Skin: Warm, moist, and intact.
Skin is pale. + edema right knee. No peripheral cyanosis. No
clubbing. No rashes or bruises present.
Diagnostics Test:
Manual muscle testing: Manual muscle testing is an attempt to
assess the maximum force a muscle can generate. In addition to
standard orthopedic and neurologic assessments, applied
kinesiology (AK) practitioners use MMT to identify what are
believed to be immediate neurological responses to a variety of
challenges and treatments (Conable, & Rosner, 2016). Testing
shows flexion at the knee of 5/5 with pain, Knee extension with
pain 5/5, Knee ER 5/5, Knee IR 5/5.
Musculoskeletal Tests: Ambulates with a limp, moderate
discomfort with flexion and extension. Positive for swelling in
both knees, slight warmth present. Positive McMurray’s and
patella grind
X-ray: Many knee problems are better diagnosed by X-ray, and
obtaining an X-ray as the first step is the usual course in
diagnosing a knee condition. X-ray can determine soft tissue
changes, bone quality, bone alignment, signs of early arthritis
and trauma and fracture. Abnormalities such as bone growths,
fractures or dislocation can be seen on the x-ray (Manaster,

17. 2017)
MRI: In orthopedics, an MRI may be used to examine bones,
joints, and soft tissues such as cartilage, muscles, and tendons
for injuries or the presence of structural abnormalities or certain
other conditions, such as tumors, inflammatory disease,
congenital abnormalities, osteonecrosis, bone marrow disease,
and herniation or degeneration of discs of the spinal cord
Blood Draws: Blood draw such as CBC and Erythrocyte
sedimentation rate( ESR)can show serum levels of substances
that can cause pain in the joints such as uric acid.
Differential
Diagnosis: 1)
Patellar tendinitis: This is the most likely diagnosis based on
the patients HPI, ROS, physical assessment, and diagnostic
studies. The patient’s chief complaint was dull pain in the knees
with occasional clicking in one or both knees. The patient is
athletic and participates in many sports that constantly put
strain on his knees. The quadriceps angle was greater than 10
which suggests patellar tendinitis. The patient plays sports that
include a lot of running and jumping which adds strain to the
knee joints. The patient was also positive for tenderness on
palpation at the inferior pole of the patella bilaterally. Lastly,
the MRI was positive for high signal intensity within the
proximal posterior central aspect of the tendon where it
originates from. 2)
Osgood Schlatter's disease: A possible diagnosis as it is a
common problem which typically occurs during times of fast
growth usually in fit active boys. Osgood Schlatter’s disease is
associated with pain just below the kneecap in one or both

18. knees, often worse after sports especially high impact activities
using the quadriceps muscles. However, limping is often a
present and the patient denied limping in the ROS. Pain is
greater with stair climbing and kneeling and the patient did not
admit to either. Flexion and extension will increase pain in the
tibial tubercle which was not present upon physical exam of the
patient.
3) Chondramalacia patellae: This is a possible diagnosis due to
the presence of knee pain upon palpitation and increased pain
with activity. However, chondramalacia patellae is more
common in females or persons with a history of knee trauma.
The patient is male and denied trauma to either knee (Dains,
Bauman & Schuber, 2016}. The patient denied a history of
misalignment which is also related to chondramalacia patellae.
An x-ray of the knee would show irregularities of the
patellofemoral joint.
4) Medial meniscus tear: This diagnosis is a possibility because
it can occur after a twisting injury and the patient participates
in sports such as soccer, basketball, and skiing that involve
twisting movements. Clicking may be present with a medial
meniscus tear which the patient reported and was also
appreciated upon physical assessment in the right knee.
McMurray test was negative for locking during joint movement.
The patient denied difficulty with weight bearing.
5) Juvenile rheumatoid arthritis (JRA): Possible due to knee
joint soreness and stiffness, however both typically improve
with activity. Joint swelling may also present with JRA and was
reported by the patient in his ROS. Patient denied weight loss
and fatigue which are common symptoms. Patient also denied
night pain. A CBC would show anemia, leukocytosis, and
thrombocytosis. The ESR would be elevated.

19. Refe
rences
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2015). Seidel's guide to physical examination
(8th ed.). St. Louis, MO: Elsevier Mosby
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced
health assessment and clinical diagnosis in primary care (5th
ed.). St. Louis, MO: Elsevier Mosby.
Rath, E., Schwarzkopf, R., & Richmond, J. (2010). Clinical
signs and anatomical correlation of patellar tendinitis. Indian
Journal of Orthopaedics, 44(4), 435-437 3p. doi:10.4103/0019-
5413.69317
Conable, K. M., & Rosner, A. L. (2016). A narrative review of
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