Patient Case Study of Knee Injury

1620 words (6 pages) Nursing Case Study

12th Feb 2020 Nursing Case Study Reference this

Tags: health

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Short case description: 25 years old, female injured her right knee during basketball game. She left playing, required little assistance to get her car. PCP evaluated her, gave her non-steroidal anti-inflammatory with P.T referral.

Brief summary of patient history: injury occurred when she planted her right leg and rotated to the right to evade a defender. She denied hearing a pop, she reported immediate pain was 8 out of 10 on a visual analog scale. Her current pain level is 5 out of 10. Patient came 2 days after injury, with knee swelling and locking. . Patient pain and mechanism of injury are consistent with a meniscus injury.

Examination:

Key Examination elements

ICF category assessing

Finding

Pain

Body structure function

5/10 with non-steroidal medication

Effusion

Body structure function

Present (first grade)

Active knee flexion

Body structure function

10-110

Active knee extension

Body structure function

0-10

Passive knee flexion

Body structure function

10-120

Passive knee extension

Body structure function

0-5

Manual Muscle test for knee flexion

Body structure function

4/5

Manual Muscle test for knee extension

Body structure function

3+/5

McMurray’s test

Health condition

Positive with palpable click

Joint line tenderness test

Body structure function

Positive with reproduction of pain on medial tibiofemoral joint

Apley’s compression test

Health condition

Positive with reproduction of pain consistent with medial meniscal injury

Ambulation

Activity limitation

Assistive tool (single cane)

Limping, antalgic gait

squatting

Activity limitation

Quite a bit difficult

Walking a mile

Activity limitation

Extreme difficulty

Going up or down  10 stairs

Activity limitation

Quite a bit difficulty

Standing one hour

Activity limitation

Extreme difficulty

Running over even ground

Activity limitation

Extreme difficulty

Ability to kook at home kitchen

participation-involvement

Quite a bit difficulty

Ability to attend social meetings

participation-involvement

Quite a bit difficulty

Usual sports activity

participation-involvement

Extreme difficulty

Assessment/evaluation: 25 Y/O female had right medial meniscus sprain with positive special Tests, pain, effusion, weakness, limited knee range of movement of flexion and extension and limited activities of daily living with inability to participate in usual sports activities.

Interventions: physical therapy treatment include:

  1. Modalities to reduce pain (whirlpool, electric stimulation, and cryotherapy).
  2. Modalities to reduce knee effusion (whirlpool, taping, pulsed ultra sound, and static quadriceps drill exercise).
  3. Intervention to restore range of motion deficits: therapeutic exercise progression, joint mobilization/ manual therapy.
  4. Therapeutic exercise to restore muscular strength and aerobic fitness.
  5. Functional strengthening exercise to return to previous level of function and participate in usual sports routine.
  6. Outcomes: After 7 weeks of rehabilitation patient get improved with following outcomes:

Outcome

ICF category

Changes at D/C

Pain

Body structure function

2/10 with strenuous activity

Effusion

Body structure function

Absent

Active knee flexion

Body structure function

0-140

Active knee extension

Body structure function

0

Passive knee flexion

Body structure function

0-140

Passive knee extension

Body structure function

0

Manual Muscle test for knee extension/ flexion

Body structure function

5/5

McMurray’s test

Health condition , disease, injury

negative

Joint line tenderness test

Body structure function

negative

Apley’s compression test

Health condition , disease, injury

negative

Ambulation

Activity limitation

Normal gait without cane

squatting

Activity limitation

No difficulty

Walking a mile

Activity limitation

No difficulty

Going up or down  10 stairs

Activity limitation

No difficulty

Standing one hour

Activity limitation

No difficulty

Running over even ground

Activity limitation

No difficulty

Usual sports activity

participation-involvement

No difficulty

Ability to attend social meetings

participation-involvement

Participating with no difficulty

Ability to kook at home kitchen

participation-involvement

Participating with no difficulty

LEFS SCALE

activity

Changes at D/C 20 points improvement to be 76/80

After 7 weeks of successful rehabilitation, patient was able to participate in routine sports activities and her daily living with no need to more medical or physical therapy assistance.

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