Case Analysis Tool Worksheet Student’s Name: Case ID: _AQ_11 I. Epidemiology/Pati
Case Analysis Tool Worksheet
Student’s Name: Case ID: _AQ_11
I. Epidemiology/Patient Profile
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Ms. Roman, a 74-year-old white female with a past medical history of GERD and a remote history of alcohol use disorder, is seen at the clinic for annual checks and with a recent complaint of knee pain. She has no prior trauma or injury history. |
II. Prioritized Cues from History and PE.
Tier 1 Tier 2 Tier 3
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Intermittent right knee pain with mildly decreased ROM |
Negative Lachman and McMurray tests |
Retired teacher |
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Crepitus with motion in the right patella |
Negative anterior and drawer tests |
No pain and normal ROM in all other joints |
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Small effusion appreciated from milking the right suprapatellar pouch |
No pain or laxity with varus or valgus stress |
Does not drink or smoke |
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No history of trauma or surgeries |
No fullness in the popliteal fossa |
No constitutional symptoms |
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Less painful in the morning, pain progresses as the day goes on |
Favors bearing weight on the left leg |
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Family history of osteoarthritis |
No erythema, edema, bruising, or atrophy |
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Describes pain as an ache and that knee grinds with movement |
Pain is keeping her from her hobby of gardening |
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Relieves with rest |
Lives in a two-story home |
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Some tenderness to palpation along both the medial and lateral joint lines on the right leg |
No skin lesions |
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Age 74-year-old |
No morning stiffness |
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No fever, numbness, weakness, or tingling |
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Ms. Roman, a 74-year-old Caucasian female, presented with two weeks of progressively worsening chronic right knee pain. She denies any knee injuries or injury. She characterizes the pain as a dull ache and assigns it a rating of 6/10 on a scale from 0 to 10. She denies experiencing numbness in the morning. She reports that the pain is less severe in the morning and increases during the day. She has solely used Bengay for pain relief. As the pain prevented her from gardening, she opted to have it examined. The physical examination reveals a mildly restricted range of motion in the right knee, along with crepitus and a little effusion, but no erythema or skin abnormalities. |
III. Problem Statement
IV. Differential Diagnosis
Leading dx: Osteoarthritis (Deveza, 2021)
History Finding(s) Physical Exam Finding(s)
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Progressively worsening chronic right knee pain |
Favoring left leg with ambulation |
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Other joint pain |
Tenderness on medial and lateral joint lines of right leg |
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Grinding sensation |
Some crepitus and small effusion on right suprapatellar pouch |
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Pain aggravates with activity and relieves with rest. |
Mildly decreased range of motion of the right knee |
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Family history of osteoarthritis |
Negative Lachman and McMurray tests |
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Female gender |
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Over 55 years of age |
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No morning stiffness |
Alternative dx: Rheumatoid Arthritis (American College of Rheumatology, 2021)
History Finding(s) Physical Exam Finding(s)
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Progressively worsening chronic right knee pain |
Absence of fever and malaise |
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Other joint paint |
No symmetric polyarthritis |
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Wrist pain |
Mild effusion |
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Pain aggravates with activity and relieves with rest. |
No nodules at pressure joints |
Alternative dx: Knee Sprain (Petrie, 2021)
History Finding(s) Physical Exam Finding(s)
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Intermittent right knee pain |
Tenderness during palpation |
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Pain aggravates with activity and relieves with rest. |
Crepitus with motion |
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No morning stiffness |
Negative Lachman and McMurray tests |
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Limited ROM of right leg. |
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V. Explanation of Diagnostic Plan and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
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History and physical |
Osteoarthritis can be diagnosed based on medical history and physical symptoms (Deveza, 2021) |
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Plain Radiograph |
It helps to confirm the diagnosis and rule out other disorders. Joint space narrowing, osteophyte formation, subchondral sclerosis, and cysts are frequently observed in OA. When osteophytes are present, patellofemoral, and tibiofemoral joint osteophytes are the most accurate indicators of disease progression, whereas joint space narrowing is the most accurate predictor of disease progression. (Deveza, 2021). |
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ESR, CBC and platelets |
OA does not cause an increase of ESR, but RA does. To rule out other differential diagnoses, especially when septic arthritis or an acute inflammatory illness is suspected. (Cash et al., 2020). |
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Rheumatoid Factor Quantitative |
The absence of rheumatoid arthritis will be determined by RA quantitative. The test’s positive predictive value is 95%, albeit it is not particularly reliable (Maru & Mulla, 2019). |
Treatment Plan Rationale
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Encourage to do exercise and weight management. |
Aerobic and strengthening exercises can have similar positive effects on pain and function as nonsteroidal anti-inflammatory drugs (NSAIDs). In conjunction with exercise, weight control can reduce knee discomfort from osteoarthritis by around 50 percent, especially in people who are overweight or obese (Abramoff & Caldera, 2020). |
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Recommend the use of a cane and knee braces if necessary. |
Canes and knee braces help alleviate pain and should be considered as supplementary treatment (Abramoff & Caldera, 2020). |
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Pharmacological management |
Due to a history of GERD, acetaminophen and topical analgesia should be used initially. Patients can begin taking 325 mg of acetaminophen orally every six hours or as needed, with a daily maximum of 4000 mg. NSAIDs are the second option, although they are associated with gastrointestinal side effects and cardiovascular risk. To prevent gastritis, omeprazole 20 mg orally at once daily can be taken in conjunction with NSAIDs. Patients might begin treatment with capsaicin cream and apply it three to four times daily (Deveza, 2021). If the patient’s symptoms persist, intra-articular injections may be indicated. Before injection, 1% lidocaine solution is combined with the steroid (Deveza, 2021). Rest and minimize joint activity for 48 to 72 hours following injection (Deveza, 2021). Oral glucocorticoids for moderate to severe rheumatoid arthritis. To avoid joint damage, the first-line treatment for RA includes disease-modifying antirheumatic medicines (DMARDs). Inform the patient of the risks, benefits, adverse effects, and warnings associated with these medications. It is also crucial that patients receive routine laboratory monitoring while taking these drugs (American College of Rheumatology, 2021). |
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Discuss immunizations, particularly for influenza and pneumonia |
DMARDs impair the immune system and increase infection risk (Cash et al., 2020). |
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Physical and Occupational Therapy |
If indicated, it should be initiated. Physical therapy strengthens muscles, enhances motion range, and diminishes pain (Deveza, 2021). |
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Surgical management |
Referral to a knee replacement surgeon is needed if all other options fail. (Cash et al., 2020). |
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Follow-up after 2 to 4 weeks |
Ms. Roman should return to the clinic for a wellness examination and evaluation of pain treatment. |
I have adhered to the honor system: Yes
Student’s signature
Abramoff, B., & Caldera, F. E. (2020). Osteoarthritis.
Medical Clinics of North America,
104(2), 293–311.
https://doi.org/10.1016/j.mcna.2019.10.007
American College of Rheumatology. (2021). Rheumatoid arthritis. American college of rheumatology.
https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Rheumatoid-Arthritis
Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines. Springer Publishing Company.
https://doi.org/10.1891/9780826153425.0018b
Deveza, L. A. (2021). Overview of the management of osteoarthritis (D. Hunter & M. R. Curtis, Eds.). UpToDate.
https://www.uptodate.com/contents/overview-of-the-management-of-osteoarthritis
Maru, D., & Mulla, E. (2019). Rheumatoid arthritis.
InnovAiT: Education and inspiration for general practice, 13(1), 13–20. SAGE Journals.
https://doi.org/10.1177/1755738019884346
Kothari, M. J. (2020). Carpal tunnel syndrome: Treatment and prognosis (J. M. Shefner & R. P. Goddeau, Eds.). UpToDate.
https://www.uptodate.com/contents/carpal-tunnel-syndrome-treatment-and-prognosis
Petrie, T. (2021). Understanding different knee injury symptoms.
Verywell Health.
https://www.verywellhealth.com/knee-injury-symptoms-5091873
The purpose of the Aquifer assignment is to teach you how to synthesize important patient information gathered during an office visit to select appropriate differentials and create subsequent diagnostic and treatment plans.
The Aquifer assignment is not a summarization of the Aquifer case, or an essay on the specific illness/disease presented.
The written portion of the Aquifer assignment should clearly outline your rationale for selecting your leading diagnosis and differentials, given the information collected for the patient presented.
While the write up needs to include an appropriately formatted title page per APA 7 guidelines, a formal introduction and conclusion are not needed.
An example outline of the written assignment should include would be as follows:
Leading Diagnosis
(this is the diagnosis for which diagnostic and treatment plan will be written)
The leading diagnosis for this patient is ****. Leading diagnosis is supported by patient’s presenting symptoms of ***** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Supporting physical assessment findings include ****** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential Diagnoses (must have 2 differentials)
Differential 1 (e.g. Influeza)
The first differential in this case is **** supported by patient presentation of *** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). The differential is further supported by physical exam findings of **** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). *** is less likely however due
*(here you would present s/s, history physical exam
findings that rule out differential)
* (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Differential 2 (e.g. Viral pharyngitis)
*** is the second possible differential in this case. Differential is supported by patient’s presenting symptoms of **** (citation). Patient’s physical assessment findings of *** further support the differential however, differential is less likely due to *** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).
Diagnostics
Here you would outline your diagnostic plan including any pertinent diagnostic test(s) or exam(s) indicated for diagnosis (must include
citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a
Problem Specific Peer Reviewed Reference
).
Brief statement regarding why test is being used, e.g. Positive RADT results are confirmatory for GAS in pediatric patients (
Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation).
Treatment Plan
*** is the first line treatment for *** (must include
citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a
Problem Specific Peer Reviewed Reference
)
Any medications should include name, route, dose, and
duration (
Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation). Supportive measures recommended, including ***** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Follow up **** (
citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings)
References
(documented per APA 7 guidelines)
Must include an appropriate clinical practice guideline unless there is not a written guideline for diagnosis. In the case no guideline is available a peer reviewed article written on the specific diagnosis selected may be used.
Aquifer Case Study #18 Family Medicine: Migraine Headaches without Aura
Student
United States University
FNP 591: Common Illnesses Across the Lifespan
Professor Georgia Strong
June 01, 2022
Leading diagnosis
The leading diagnosis for S.P. is migraine headaches without aura. A diagnosis of migraine headaches without aura is supported by the patient’s report of unilateral and severe throbbing pain associated with nausea, photophobia, and hyperacusis occurring 2-3 times weekly (Cutrer, 2022). S.P meets 5 of the ICHD-3 diagnostic criteria for migraine without aura, including 1) having 5 attacks 2) headache attacks that last 4-72 hours, 3) characteristics such as unilateral pulsating headache, 4) nausea, vomiting, and photophobia during headache, and 5) does not match other ICHD-3 diagnosis (Cutrer, 2022).
Differential Diagnoses
Differential diagnoses for this patient include cluster-type headaches and anxiety.
Cluster-Type Headaches
The first differential for S.P. is cluster-type headaches, supported by a debilitating unilateral and severe throbbing pain that’s associated with nausea, photophobia, and hyperacusis that occurs 2-3 times a week and results in the patient having to go home. However, this is ruled out due to lack of autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, sweating, and/or nasal congestion (May, 2022).
Anxiety
Another differential is headache due to anxiety supported by S.P. ‘s report of a stressful lifestyle with schooling, part time work, and recent breakup with a boyfriend who cheated. (Taylor, 2020). However, this is ruled out as the patient’s GAD-2 score was 2, testing negative (Taylor, 2020).
Diagnostics
Diagnostic testing of MRI for migraine isn’t needed in this patient given her age of under 50 or having cognitive changes (Ng & Hanna, 2021). The patient would not need other laboratory tests given the negative physical examination (Cutrer, 2022).
Treatment Plan
S.P. ‘s migraine can be treated with oral sumatriptan 100 mg PO as needed for headaches and can be repeated in 2 hours, but do not exceed over 200 mg in a 24-hour period (Ng & Hanna, 2021). The patient can also take a combo therapy of acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg orally PRN for tension-type headaches (Taylor, 2020). The patient should reduce her caffeine intake from other sources if it’s a trigger for her headaches.
S.P. should have a follow up appointment in 2 weeks to see if the medication worked. The patient in the meantime should keep a journal of headache triggers and patterns and reduce stressors in her life that could contribute to the tension-type headaches. She can also exercise four times a week, use relaxation therapies, and improve sleep (Schwedt & Garza, 2022).
References
Cutrer, M. (2020). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults.
UpToDate. Retrieved June 12, 2022, from
https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
May, A. (2022). Cluster headache: Epidemiology, clinical features, and diagnosis.
UpToDate. Retrieved June 12, 2022, from
https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis?search=cluster%20headache&source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1#H6
Ng, J. Y., & Hanna, C. (2021). Headache and migraine clinical practice guidelines: A systematic review and assessment of Complementary and Alternative Medicine Recommendations.
BMC Complementary Medicine and Therapies,
21(1). https://doi.org/10.1186/s12906-021-03401-3
Schwedt, T. & Garza, I. (2020). Acute treatment of migraine in adults.
UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7
Taylor, F. (2020). Tension-type headache in adults: Acute treatment.
UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20headache&topicRef=3357&source=see_link#H8