NR 577: PRIMARY CARE MANAGEMENT OF ADOLESCENTS &
ADULTS UPDATED EXAM STUDY GUIDE (WEEK 5-8)
If you understand the concepts below and how to diagnose, treat, and manage, you will be successful on the Final exam.
Week 5: Musculoskeletal and Neurological Disorders
Musculoskeletal Disorders
▪ Scoliosis
▪ Patellofemoral stress syndrome
Patellofemoral overuse syndrome occurs during running and sports that involve repetitive stress in the lower
extremity. The athlete presents with activity-related pain in the anterior knee. In young athletes, it is occasionally
associated with swelling and crepitus of the knee joint.
Evaluation of these injuries is comprehensive and requires a “top-down” evaluation of the athlete’s leg from the hip
to the foot. Most athletes with this condition, regardless of level or physical condition, typically have hip/core
weakness that results in altered knee biomechanics. A comprehensive evaluation of hip alignment and rotation,
muscle development, tightness in the hamstrings and IT band, and foot mechanics is necessary to fully understand
and treat the cause of this disorder. Most athletes with this complaint often have a multifactorial cause for their
symptoms.
Treatment should be geared toward identifying the cause. Often, athletes are overtraining and need to modify
current activities. Cross-training may help. Addressing hip and pelvic stability is now a mainstay of treatment for
this disorder. Stretching and strengthening of the hamstrings and quadriceps are recommended. The use of braces
providing proprioceptive feedback during competition is controversial.
▪ Growing Pains
“growing pains” of presumed bone and joint origin of children.
Growing pains, a common cause of leg pain in childhood, are characterized by poorly localized pain at night, which
frequently wakes the child from sleep; no objective signs of inflammation; and no daytime symptoms. Patients with
growing pains often ask to be massaged, which is not typical of those with arthritis.
▪ Shin splints
The term shin splints is widely used for shin pain, but it is not a diagnostic term. A more specific diagnosis should be
made if possible. Shin splints usually occur in the beginning of training after a relatively inactive period. The pain
and tenderness are located over the anterior compartment and disappear in 1 to 2 weeks as the athlete becomes
conditioned to the exercise. Care must be taken to differentiate shin splints from stress fractures of the tibia, which
cause more localized pain and have many more potential complications if not cared for properly.
▪ Osgood-Schlatter disease (OSD)
active adolescents during growth spurts, ages of 9 and 15 when the tuberosity has not yet been ossified
area is not hard enough to resist traction of the patellar ligament, common in young adolescents who play sports
requiring repetitive quadriceps contractions, such as basketball, soccer, or figure skating
overuse syndrome that presents with pain, tenderness, and edema to the affected knee.
typically resolves by itself as ossification of the tuberosity continues as the child grows.
Signs and Symptoms
• pain worsened by activity such as running, jumping, squatting, using stairs
• palpable lump below the knee
• localized erythema, swelling, and tenderness
• may be unilateral or bilateral
Treatment for Osgood-Schlatter disease includes:
• anti-inflammatory medication (ibuprofen) to reduce pain and swelling
• stretching, flexibility, and physical therapy exercises for the thigh and leg muscles
• surgery may be required for persistent pain or progressive disease
• RICE (rest, ice, compression, elevation) may be helpful to manage pain and inflammation
, Neurological Disorders
▪ EEG
a patient with suspected epilepsy, the presence of seizure activity during the EEG establishes the diagnosis.
The absence of seizure activity does not exclude the diagnosis of a seizure disorder since focal seizures can
originate from areas of the cortex that cannot be detected by scalp electrodes.
It is often difficult to obtain an EEG during a seizure. Procedures may be used to provoke abnormal activity:
o hyperventilation
o photic stimulation
o sleep deprivation on the night prior to the EEG
▪ Seizures
1. Simple partial seizures
Focal seizures are classified by whether there is preserved awareness (formerly called simple partial seizures) or impaired awareness (formerly
called complex partial seizures), and whether the first manifestation is a motor feature or not.
In focal seizures, the seizure is confined to one area of the brain. It usually involves just one hemisphere or one small part of a hemisphere. The
symptoms are dependent upon the area of the brain affected as well as the spread of the seizure. If the focal seizure is confined to the motor area
of the brain, the symptoms produced are the muscle jerking in one area. Some patients also exhibit turning of the head to one side. If the focal
seizure occurs in the vision part of the brain, the symptoms are usually flashings of light which are only perceived by the patient. If the focal
seizures occur in the auditory cortex, the patient will perceive a ringing sound in the ear. If it occurs in the sensory area of the brain, it is
perceived as false touch sensations.
Focal seizures without dyscognitive features: there is no impairment of consciousness. The patient remains conscious during the seizure and able
to interact normally with the surroundings. These were previously classified as simple partial seizures.
Focal seizures with dyscognitive features: there are marked impairment of consciousness without loss of consciousness. The patient appears to be
awake but does not interact or answer questions. These were previously classified as complex-partial seizures.
2. Grand mal seizures
Major motor seizure—grand mal
Consciousness is lost without warning and the patient is amnestic for the event. Except for the absence of any
evidence of focal onset, the seizure is identical to a secondary generalized seizure.
3. Anti-epileptic/Seizure medications
The American Academy of Neurology (2015) provides guidelines on the decision to initiate AED treatment. Immediate AED
treatment after a first unprovoked seizure should be based on individualized patient assessments that account for the risk for
seizure recurrence against the adverse effects of AED therapy. Patient preferences should also be considered. Patients should be
advised that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce the seizure risk over
the subsequent 2 years. Provoked seizures should initially be treated based on the underlying cause.
Phenytoin should be monitored for therapeutic drug levels. Creatinine, CBC, and liver function should be monitored annually. The
patient should also receive regular dental exams.
Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and LFTs every 3
months for 1 year and then annually.
Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Draw CBC, LFT, and renal function every 3 months
for 1 year and then annually.
