Case study Case study

11

CASE STUDY

Casestudy

Casestudy

Assessment

John,a Hispanic male teenager and a high school student, is brought to thefacility for an annual flu vaccine but has a swollen and painfulright knee especially when walking. John is an athletic teenage whoplays basketball in his school team. His knee has had a problem forat least two months with no history of injury. The pain is relievedby rest, ibuprofen or ice compression. This has resulted into declinein sporting performance and affects his grades in school. This hasmade his father very concerned.

  1. Differential diagnosis

OssgoodSchlatter disease: ruled out

OssgoodSchlatter disease is an inflammation disease that affects thepatellar ligament in the tibia tuberosity (Lucena et al 2010).Ossgood Schlatter disease is more common among adolescent involved inintense sport which involves jumping and running. Although symptomsare likely to vary from one person to another, the main symptom ispain below the knee. Some patients experience incapacitatingcontinuous pain while others have movement associated pain. Thesymptoms recur lasting a few weeks to months until the individualstops growing. Swollen and painful knees require urgent medicalattention (Bloom, 2004, Ogden, 2000). Examination of john does notsuggest that he is suffering from Ossgood Schlatter disease. The painand inflammation of the knee is not confined to the lower part of theknee. Additionally, the pain is only experienced during ambulationand goes away when he rests. The X-ray imaging indicates ossificationat the artucular surfaces rather than inflammation of the patellarligament on the tabia. Therefore, Ossgood Schlatter disease is ruledout in John’s cases.

Meniscustear: ruled out

Meniscustear is one of the most common knee injuries, especially amongsportsmen. The tear results from a forceful twist or rotation of theknee with full weight support by the particular foot. Meniscus is theC shaped cartilage in the knee which cushions above the tibiae(Goldblatt et al 2009). Although protection such as correct footwearduring sports, strengthening of leg muscles through stretching andproper sport techniques are more appropriate, physical therapy is themain treatment option for mild tears. However, serious tears mayrequire surgical procedures (Poulsen &amp Johnson, 2011, Snoeker etal, 2003). There is no likelihood of John suffering from meniscustear. This is because the inflammation did not result from an injuryand the causes of inflammation are visible in the X-ray image.

  1. Definitive diagnosis

Osteochondritisdissecans

Osteochondritisdissecans disease which is abbreviated as OCD is a joint disorderwhich results from cracks in the articular cartilage and subchondralbone (Berndt &amp Harty, 2014). Osteochondritis dissecans is arelatively rare desease affecting one to three people in a populationof ten thousand. It is more common among adolescent who are morephysically active (KocherKocher et al, 2007). However, due to theirage, they are more chances of full recovery compared to adults whosebones have less ability to repair. Osteochondritis dissecans canaffect any joint, but it over three quarters of the cases involvesthe knee joints. The main causes of Osteochondritis dissecans are notclear (Brian &amp Mike, 2013). It accounts for majority of hospitalvisits associated with Osteochondritis dissecans. The main symptom ofOsteochondritis dissecans is movement related pain, inflammation andpopping noise (Hixon &amp Gibbs, 2000).

Preliminaryexamination suggests that John could be suffering fromOsteochondritis dissecans. He is a very active adolescence and anessential member of his school basketball team. He complains ofmovement related pain and welling on the right knee, a major symptomof Osteochondritis dissecans. Basketball is associated withrepetitive strain injuries, some of which do not receive any medicalattention. Examination of the quadriceps on the affected kneeindicates tenderness and effusion. The right knee is also externallyrotated when John is walking. An X-rays image confirms that john issuffering from Osteochondritis dissecans (Widuchowski et al 2007).

Plan

Diagnosisplan

  • Repeated history

  • Physical extermination

  • Diagnostic imaging

Therapeuticplan

  • Administration of annual flu vaccine.

  • Administering anti inflammation medication to reduce the swelling and pain. Codeine (Tylenol) PO 60mg every 4-6hr.

  • Recommend reduced physical activities and immobilization for six weeks.

  • Protective weight bearing of the right knee.

  1. Social diagnosis

Johnis also suffering from a sociological problem. It is important tonote that he is a teenager. Anxietydisorder

Anxietyis common emotional disorder that affects a wide range ofindividuals. However, anxiety disorder is a more serious emotionalproblem that is likely to disrupt an individual’s normal life. Someof the general signs of anxiety disorders include panic anduneasiness, lack of sleep and inability to remain calm. Studiesindicate that anxiety disorders are not as a result of personalweaknesses or poor upbringing, but are caused by stressingenvironment. John is anxious about the constant financial argumentsbetween his parents and the financial instability of the family.

  1. Drug abuse

Drugabuse is one of the most important social issues affecting theteenagers. In the modern society the youths start using drugs at avery early age. Drug abuse is diagnosed through psychiatricevaluation of the patient. Laboratory tests can also be done todetermine the type of drug abused and the extent of abuse. Diagnosticand Statistical Manual of Mental Disorders (DSM-5) is the majorcriterion used in diagnosis of drug abuse. John has admitted that hehas started using drugs mainly due to influence from his peers.However, he does not want his father to know anything about it.

  1. Depression

Depressionis another important sociological problem affecting teenagers in themodern society. Depression is closely related with other sociologicalproblems such as drug abuse and stress. Depression is diagnosedthrough physical examination of the patient, laboratory tests andpsychiatric evaluation. Evaluation of john indicates that he may besuffering from depression.In the recent past, John grades havebeen deteriorating and his performance in the basket ball team isdeclining. Additionally, he does not listen to his parents andsometimes sleeps out without the knowledge of his parents.

Plan

Diagnosisplan

  • Sociological history.

  • Laboratory tests for drugs.

  • Specialized psychiatric evaluation

Therapeuticplan

  • Psychiatric counseling.

  • Drug abuse rehabilitation.

  • Psychosocial support.

Patienteducation

Johnand his father verbalized understanding of the importance of physicaltherapy, the use of weight bearing and palliative medication, therole of immobilization and rest in the treatment of the condition. Additionally, the importance of visiting a specialized orthopedicconsultant was emphasized and the understanding assessed. Selfmonitoring was also advised and the understanding was evaluatedthrough verbalization of the understanding. Any sign of distress thatwould require specialized attention was explained in details to bothJohn and his father. Both electronic and non electronic resourceswere reviewed and the understanding verbalized. A brochure onmanagement of Osteochondritis dissecans was handed to John and hisfather to understand his condition better. The following internetresources were reviewed

http://www.aafp.org/afp/2000/0101/p158.html

http://www.patient.co.uk/doctor/osteochondritis-dissecans

http://www.childrenshospital.org/conditions-and-treatments/conditions/osteochondritis

Follow-upsand referrals

  • Follow-ups a return clinic after two weeks from the day of treatment.

  • Follow-ups: Imaging to be done every three months to monitor the progress of the not operative therapy.

  • Referral: referral to an orthopedic consultant on Tuesday next week at 1000hrs.

  • Referral: Referral for more specialized treatment, surgical treatment in case of low progress in healing (LützneLützner et al, 2007).

  • Referral: Psychiatric treatment for sociological problems and drug abuse. This will be essential in dealing with the adolescence challenges and understanding his medical condition.

  • Follow-ups: Administration of other missing immunizations including dose #2 (booster), Tdap dose #2 and HPV dose #1.

Adolescenthealth care

Adolescentsconstitute about 21 percent of the global population. Therefore, thehealth condition of this group has a huge impact on the global healthcare system. Adolescences are at a risky and critical stage ofdevelopment. Their risky behaviors can result into health challengesthat will affect their adulthood health (Steinberg, 2011). There areimportant global health care concerns that affect adolescence, whichincludes substance abuse, teenage pregnancies and irresponsiblesexual behaviors, homicide and suicidal thoughts. Adolescences areeasily influenced by their peers or the environment which puts themat risk of activities that affect their health. Despite this, theyare ignored since the society assumes that they are adults who canmake right decisions. As a result, majority of the health care issuesamong adolescence are not addressed in the health care faculties(Neinstein et al 2008).

Nurseshave an important role in adolescent patient care. However, theeffectiveness in caring for the adolescence is dependent on whetherthe nurse understands the needs of this group of patients. Nurseshave a responsibility of creating a health care environment in whichadolescence are comfortable. A good number of teenagers are unwillingto visit a medical care facility because of the environment (Phelps &ampCraig, 2008). In John’s case, although he had a swollen andpainful knee and a pending annual immunization, he was reluctant togo to the healthcare facility. Teenagers in John’s situation arelikely to ignore major health issues that can have a huge impact ontheir lives.

Johnis disturbed by the challenges affecting his family and thus he isreluctant of seeking medical attention. Due to the family challenges,John has also started using drugs. Family related challenges have ahuge impact on adolescent health. An effective strategy is thereforenecessary to deal with health challenges in adolescents. Thisincludes strategies that ensure that the teenagers are able to accesshealth care services despite the family dynamics. One of the mosteffective methods is the use of peer educators where teenagers whoare more cooperative and have a stronger family and social supportare used to reach other youths (Neinstein et al 2008).

References

Berndt,A. L. &amp Harty, M. ( 2004). &quotTranschondral fractures(osteochondritis dissecans) of the talus&quot. Journalof Bone and Joint Surgery(American) 86 (6): 1336.

Bloom,J. (2004). &quotWhat is the best treatment for Osgood-Schlatterdisease?&quot, Journalof Family Practice,vol 53(2), p 153–156.

Brian,J. C. &amp Mike, M. (2013). ArticularCartilage Lesions A Practical Guide to Assessment and Treatment,New York, NY. Springer New York.

Goldblatt,J.P., LaFrance, R.M. &amp Smith, J.S. (2009). &quotManagingmeniscal injuries: The treatment&quot. Journalof Musculoskeletal Medicine 26(12): 471–7.

HixonA. L. &amp Gibbs L. M. (2000). &quotOsteochondritis dissecans: adiagnosis not to miss&quot. AmericanFamily Physician 61(1): 151–6, 158.

KocherKocherM. S., Czarnecki J. J., Andersen J. S. &amp Micheli L. J. (2007).&quotInternal fixation of juvenile osteochondritis dissecans lesionsof the knee&quot. AmericanJournal of Sports Medicine35 (5): 712–8.

Lucena,G. L., Gomes, C. A., &amp Guerro R. O. (2010). “Prevelance andAssociated Factors of Osgood-Schlatter Syndrome in a Population-BasedSample of Brazilian Adolescents”. TheAmerican Journal of Sports Medicine,39, 415-420.

LützneLütznerJ, Mettelsiefen J, Günther KP, Thielemann F (2007). &quotTreatmentof osteochondritis dissecans of the knee joint&quot. DerOrthopäde (in German)36 (9): 871–9

Neinstein,L. S et al (2008). Adolescenthealth care: a practical guide, Philadelphia:Lippincott Williams &amp Wilkins.

Ogden,J. A. (2000). Skeletalinjury in the child,New York: Springer.

Phelps,K. &amp Craig H. (2008). AdolescentHealth &amp Development: General Practice: The Integrative ApproachSeries. London:Elsevier Health Sciences APAC.

PoulsenM. R. &amp Johnson D. L. (2011). &quotMeniscal injuries in theyoung, athletically active patient&quot. PhysSportsmed39 (1): 123–30.

Snoeker,B. A. Bakker, E. W. Kegel, C. A. &amp Lucas, C. (2013). &quotRiskfactors for meniscal tears: a systematic review includingmeta-analysis.&quot. JOrthop Sports PhysTher 43 (6): 352–67.

Steinberg,L. (2011). Adolescence, New York, NY: McGraw-Hill.

WiduchowskiW, Widuchowski J, Trzaska T (2007). &quotArticular cartilagedefects: study of 25,124 knee arthroscopies&quot. TheKnee14 (3): 177–82.