A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click
Assessing Musculoskeletal Pain
Case 3: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
With regard to the case study you were assigned:
· Review this week\\\’s Learning Resources, and consider the insights they provide about the case study.
· Consider what history would be necessary to collect from the patient in the case study you were assigned.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\\\’s condition. How would the results be used to make a diagnosis?
· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\\\’s differential diagnosis and justify why you selected each.
Expert Answer and Explanation
Knee Pain Episodic/Focused SOAP Note
Patient Information:
JD is a 15-year-old African American Male.
S.
CC “Dull pain in both knees for four days.”
HPI: JD is a 15-year-old African American Male who came to the hospital with complaints of dull pain in his both knees for the three days. He reports that he sometimes feels catching sensation under the patella and both knees often click. The pain started after playing basketball tournament three days ago. He has not applied any medication. The severity of the pain I 8/10.
Current Medications: No medications
Allergies: No allergies.
PMHx: No history of major medical conditions. Pneumonia and influenza vaccines are up to date.
Soc Hx: Denies tobacco or alcohol use. He is the only child in a middle-class family. He loves playing basketball.
Fam Hx: He is the only child in a family of three. Both parents are alive and healthy. Grandfather died of depression. He committed suicide. Grandmother is alive as has type II diabetes.
ROS:
GENERAL: No fatigue, weight loss, or fever.
HEENT: Eyes: No vision problems. Ears, Nose, Throat: No hearing problem, sneezing, runny nose, congestion, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No heart problems.
RESPIRATORY: No breathing problems.
MUSCULOSKELETAL: Knee pain.
HEMATOLOGIC: No anemia or bleeding.
O.
Physical exam:
Constitutional: General Appearance: Healthy adult with moderate distress. A+O+3, mucous membranes moist, flushed, answers questions properly. Vitals: BP 122/90; P 57; R 20; T 36.3; W 58kgs; H 157cm.
HEENT: Head: NC/AT. Eyes: Pupils are PERRL, extraocular movements intact; conjunctivae pink. Ears: Hearing intact, normal external appearance. Nose: Appears normal, clear mucus. Mouth: The are in good shape. Throat: No lesions or inflammation of the tonsils.
Skin: Normal color for ethnicity, dry, warm, with no rashes or lesions.
Cardiovascular: S1, S2 with regular rhythm and rate. No heart sounds.
Lungs: Chest walls symmetric. Lungs clear and bilateral. Regular respirations.
Knee: MRI shows ACL tear in both knees.
Diagnostic results: Diagnosis for knee musculoskeletal can be done using MRI or X-ray (Ball et al., 2019). The authors note that X-ray cannot see the ligaments, and in this case, MRI is recommended.
- X-ray: Pending
- MRI: Pending
A.
Differential Diagnoses
- Anterior Cruciate Ligament (ACL) Injury. The primary diagnosis for this ACL injury. ACL injury is a sprain or tear ACL, one of the major ligaments in the knee (Korakakis et al., 2019). The injury occurs mostly in sportspersons. The disease causes pain in the knee. It has been included as the primary diagnosis because the patient is a sportsperson and recently got injured during a game.
- Knee locking: Characteristics of knee locking include catching sensation, swelling of the affected knee, and pain with extension (Lee, Nixion, Chandratreya & Murray, 2017). The disease is not a primary diagnosis because the patient is no swelling in the knee.
- Osteochondritis Dissecans: OCD is a joint condition that occurs when blood is not enough in the end of the bone. It also causes pain in the knee, and that is why it has been included in the diagnosis.
- Juvenile idiopathic arthritis: JIA is the swelling of the joints. The disease occurs before a kid reaches 16 years (Ramanan et al., 2017). It causes joint pain, and that is why it has been included in the diagnosis.
- Repeated kneecap dislocation: Repeated patellar subluxation is the continued instability of the patellar, which causes knee pain.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel\’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Korakakis, V., Saretsky, M., Whiteley, R., Azzopardi, M. C., Klauznicer, J., Itani, A., … & Malliaropoulos, N. (2019). Translation into modern standard Arabic, cross-cultural adaptation and psychometric properties’ evaluation of the Lower Extremity Functional Scale (LEFS) in Arabic-speaking athletes with Anterior Cruciate Ligament (ACL) injury. PloS one, 14(6), e0217791. https://doi.org/10.1371/journal.pone.0217791
Lee, P. Y. F., Nixion, A., Chandratreya, A., & Murray, J. M. (2017). Synovial plica syndrome of the knee: a commonly overlooked cause of anterior knee pain. The Surgery Journal, 3(1), e9. doi: 10.1055/s-0037-1598047
Ramanan, A. V., Dick, A. D., Jones, A. P., McKay, A., Williamson, P. R., Compeyrot-Lacassagne, S., … & Beresford, M. W. (2017). Adalimumab plus methotrexate for uveitis in juvenile idiopathic arthritis. New England Journal of Medicine, 376(17), 1637-1646. https://www.nejm.org/doi/full/10.1056/NEJMoa1614160
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