My post with my instructors response
Hello Class and Dr. J
CC: Pain to foot
PMHx: overweight no other significant history. Family history father is obese and had gastric
bypass surgery x1year ago no other significant history for the family. Does not smoke, drink
ETOH or caffeine or use illicit drugs
Demographics: 16-Year-old Hispanic male, high school student, lives with both parents and has
insurance
Medications: Multi-Vitamin
PSHx: none reported
Allergies: NKDA
Lifestyle: participates in school football and weightlifting
HPI: DG is a 16-year-old Hispanic male who presented to the clinic with father c/o left foot pain
reporting that a 40 lb. Dumbbell slipped out of his hand while lifting weights at the school gym x
2 days ago. Initially did not hurt but upon returning home from school after the workout, it began
to hurt describing the pain as throbbing to the left top of the foot. Able to bear weight only
complains of 3 out of 10 on the pain scale. Aggerating factors are weight bearing and unable to
put on tennis show. Denies any ice, elevation or wrapping the extremity and the no additional
medication for pain.
Associated risk factors/ demographics contributing to foot pain- pain to the left foot
associated risk factors contributing to the chief complaint physical activity due to lifting weights
and inability to repeatedly lifting the weight and maintain control of the weight due to
unsupported strength. Inappropriate shoes for the specific activity.
Differential Diagnosis represented by CC including pathophysiology and rationale
Stress fracture
1. Pathophysiology: When a bone is broken the periosteum and blood vessels in the cortex,
marrow, and surrounding soft tissues are disrupted. Bleeding occurs from the damaged
ends of the bone and from the neighboring soft tissue. A clot (hematoma) forms within
the medullary canal, between the fractured ends of the bone. (McCance, 2015).
2. Rationale: it is activity induced there is also discomfort with activity, tenderness to dorsal
aspect of the foot, occurred with trauma
Tendinitis
1. Pathophysiology: Symptomatic degeneration of the tendon with vascular disruption and
inflammatory repair response. inflammatory fluid accumulates causing swelling of the
tendon and its enclosing sheath (McCance, 2015). Inflammatory changes cause
thickening of the sheath, which limits movements and causes pain. Microtears cause
bleeding, edema, and pain in the involved tendons or surrounding structure.
2. Rationale: discomfort, tenderness and mild swelling to the left dorsal medial aspect of the
foot.
Sprain
1. Pathophysiology: When a tendon or ligament is torn, an extensive cascade of
inflammatory processes begins. An inflammatory exudate develops between the torn
ends. Later, granulation tissue containing macrophages, fibroblasts, and capillary buds
grows inward from the surrounding soft tissue and cartilage to begin the repair process
(McCance, 2015). Within 3 to 4 days after the injury, collagen formation begins. At first,
collagen formation is random and disorganized. As the collagen fibers interweave and
, connect with pre-existing tendon fibers, they become organized parallel to the lines
of stress.
2. Rationale- pain, swelling and bruising to left foot, able to move affected foot with
discomfort.
Stress fracture, tendinitis, and sprain differ in occurrence: Acute stress fractures primarily result
from significant trauma. Motor vehicle accidents, sports injury, falls, and assaults are among the
most common causes of these injuries (NLM, 2018). Previous data for all types of fractures have
shown an annual incidence of 21 fractures per 1000 people per year in the US, with a higher
incidence in males than in females (NLM, 2018). Tendinitis occurrence 1% to 3% annual
incidence of lateral epicondylitis, which affects men and women equally (NLM, 2018). It is more
common in people aged >40 years. Affects millions of people in athletic and occupational
settings as well as the general population. Because it affects such a diverse population and can
occur at different sites, the true incidence is unknown. However, it is estimated that half of all
sports injuries are secondary to overuse. Of these injuries, the muscle-tendon unit is the most
commonly affected (NLM, 2018). The occurrence in sprains around 30% to 50% of
musculoskeletal (tendon/muscle/bone) injuries presenting to physicians are tendon and ligament
injuries. Among those injuries, an acute injury is one of the most common musculoskeletal
injuries in athletes and sedentary people, accounting for an estimated 2 million injuries per year
and 20% of all sports injuries in the US. (NLM, 2018). There is no gender difference, but the
incidence depends on the type of sports or activities. (NLM, 2018).
Stress fracture, tendinitis, and sprain differ in pathophysiology: When a bone is broken the
periosteum, and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted.
Bleeding occurs from the damaged ends of the bone and the neighboring soft tissue. A clot
(hematoma) forms within the medullary canal, between the fractured ends of the bone.
(McCance, 2015). With tendinitis, there is asymptomatic degeneration of the tendon with
vascular disruption and inflammatory repair response. Inflammatory fluid accumulates causing
swelling of the tendon and its enclosing sheath (McCance, 2015). Inflammatory changes cause
thickening of the sheath, which limits movements and causes pain. Microtears cause is bleeding,
edema, and pain in the involved tendons or surrounding structure. When a sprain occurs
pathophysiological a tendon or ligament is torn, an extensive cascade of inflammatory processes
begins. An inflammatory exudate develops between the torn ends. Later, granulation tissue
containing macrophages, fibroblasts, and capillary buds grows inward from the surrounding soft
tissue and cartilage to begin the repair process (McCance, 2015). Within 3 to 4 days after the
injury, collagen formation begins. At first, collagen formation is random and disorganized. As the
collagen fibers interweave and connect with pre-existing tendon fibers, they become organized
parallel to the lines of stress.
Stress fracture, tendinitis and sprain differ in presentation: Sprains can be extremely painful, and
are easy to confuse as a break. Many times, they are more painful than a fracture, which has been
confirmed (Skinner, 2014). However, the presentation of a sprain is usually: Pain around the
injury area, swelling around the injury area, mild bruising around the area, limited range of
motion in the joint that is affected, at the exact time of injury, you may hear the sound of a pop in
a joint (Skinner, 2014). If you do not here one, you will feel one. Whereas a stress fracture is not
always obvious in presentation such as severe swelling over top of a bone; bruising over top of a
bone, deformity of the injured area, pain that increases when pressure is applied or the area is
moved, inability to use the injured limb or bone poking through the skin (Skinner, 2014). In
Hello Class and Dr. J
CC: Pain to foot
PMHx: overweight no other significant history. Family history father is obese and had gastric
bypass surgery x1year ago no other significant history for the family. Does not smoke, drink
ETOH or caffeine or use illicit drugs
Demographics: 16-Year-old Hispanic male, high school student, lives with both parents and has
insurance
Medications: Multi-Vitamin
PSHx: none reported
Allergies: NKDA
Lifestyle: participates in school football and weightlifting
HPI: DG is a 16-year-old Hispanic male who presented to the clinic with father c/o left foot pain
reporting that a 40 lb. Dumbbell slipped out of his hand while lifting weights at the school gym x
2 days ago. Initially did not hurt but upon returning home from school after the workout, it began
to hurt describing the pain as throbbing to the left top of the foot. Able to bear weight only
complains of 3 out of 10 on the pain scale. Aggerating factors are weight bearing and unable to
put on tennis show. Denies any ice, elevation or wrapping the extremity and the no additional
medication for pain.
Associated risk factors/ demographics contributing to foot pain- pain to the left foot
associated risk factors contributing to the chief complaint physical activity due to lifting weights
and inability to repeatedly lifting the weight and maintain control of the weight due to
unsupported strength. Inappropriate shoes for the specific activity.
Differential Diagnosis represented by CC including pathophysiology and rationale
Stress fracture
1. Pathophysiology: When a bone is broken the periosteum and blood vessels in the cortex,
marrow, and surrounding soft tissues are disrupted. Bleeding occurs from the damaged
ends of the bone and from the neighboring soft tissue. A clot (hematoma) forms within
the medullary canal, between the fractured ends of the bone. (McCance, 2015).
2. Rationale: it is activity induced there is also discomfort with activity, tenderness to dorsal
aspect of the foot, occurred with trauma
Tendinitis
1. Pathophysiology: Symptomatic degeneration of the tendon with vascular disruption and
inflammatory repair response. inflammatory fluid accumulates causing swelling of the
tendon and its enclosing sheath (McCance, 2015). Inflammatory changes cause
thickening of the sheath, which limits movements and causes pain. Microtears cause
bleeding, edema, and pain in the involved tendons or surrounding structure.
2. Rationale: discomfort, tenderness and mild swelling to the left dorsal medial aspect of the
foot.
Sprain
1. Pathophysiology: When a tendon or ligament is torn, an extensive cascade of
inflammatory processes begins. An inflammatory exudate develops between the torn
ends. Later, granulation tissue containing macrophages, fibroblasts, and capillary buds
grows inward from the surrounding soft tissue and cartilage to begin the repair process
(McCance, 2015). Within 3 to 4 days after the injury, collagen formation begins. At first,
collagen formation is random and disorganized. As the collagen fibers interweave and
, connect with pre-existing tendon fibers, they become organized parallel to the lines
of stress.
2. Rationale- pain, swelling and bruising to left foot, able to move affected foot with
discomfort.
Stress fracture, tendinitis, and sprain differ in occurrence: Acute stress fractures primarily result
from significant trauma. Motor vehicle accidents, sports injury, falls, and assaults are among the
most common causes of these injuries (NLM, 2018). Previous data for all types of fractures have
shown an annual incidence of 21 fractures per 1000 people per year in the US, with a higher
incidence in males than in females (NLM, 2018). Tendinitis occurrence 1% to 3% annual
incidence of lateral epicondylitis, which affects men and women equally (NLM, 2018). It is more
common in people aged >40 years. Affects millions of people in athletic and occupational
settings as well as the general population. Because it affects such a diverse population and can
occur at different sites, the true incidence is unknown. However, it is estimated that half of all
sports injuries are secondary to overuse. Of these injuries, the muscle-tendon unit is the most
commonly affected (NLM, 2018). The occurrence in sprains around 30% to 50% of
musculoskeletal (tendon/muscle/bone) injuries presenting to physicians are tendon and ligament
injuries. Among those injuries, an acute injury is one of the most common musculoskeletal
injuries in athletes and sedentary people, accounting for an estimated 2 million injuries per year
and 20% of all sports injuries in the US. (NLM, 2018). There is no gender difference, but the
incidence depends on the type of sports or activities. (NLM, 2018).
Stress fracture, tendinitis, and sprain differ in pathophysiology: When a bone is broken the
periosteum, and blood vessels in the cortex, marrow, and surrounding soft tissues are disrupted.
Bleeding occurs from the damaged ends of the bone and the neighboring soft tissue. A clot
(hematoma) forms within the medullary canal, between the fractured ends of the bone.
(McCance, 2015). With tendinitis, there is asymptomatic degeneration of the tendon with
vascular disruption and inflammatory repair response. Inflammatory fluid accumulates causing
swelling of the tendon and its enclosing sheath (McCance, 2015). Inflammatory changes cause
thickening of the sheath, which limits movements and causes pain. Microtears cause is bleeding,
edema, and pain in the involved tendons or surrounding structure. When a sprain occurs
pathophysiological a tendon or ligament is torn, an extensive cascade of inflammatory processes
begins. An inflammatory exudate develops between the torn ends. Later, granulation tissue
containing macrophages, fibroblasts, and capillary buds grows inward from the surrounding soft
tissue and cartilage to begin the repair process (McCance, 2015). Within 3 to 4 days after the
injury, collagen formation begins. At first, collagen formation is random and disorganized. As the
collagen fibers interweave and connect with pre-existing tendon fibers, they become organized
parallel to the lines of stress.
Stress fracture, tendinitis and sprain differ in presentation: Sprains can be extremely painful, and
are easy to confuse as a break. Many times, they are more painful than a fracture, which has been
confirmed (Skinner, 2014). However, the presentation of a sprain is usually: Pain around the
injury area, swelling around the injury area, mild bruising around the area, limited range of
motion in the joint that is affected, at the exact time of injury, you may hear the sound of a pop in
a joint (Skinner, 2014). If you do not here one, you will feel one. Whereas a stress fracture is not
always obvious in presentation such as severe swelling over top of a bone; bruising over top of a
bone, deformity of the injured area, pain that increases when pressure is applied or the area is
moved, inability to use the injured limb or bone poking through the skin (Skinner, 2014). In
