CASE STUDY INFO WITH ??? AT THE

CASE STUDY INFO WITH ??? AT THE BOTTOM Differential Diagnosis for Knee Pain Diagnosis Location of pain History of trauma Fever, systemic symptoms Special notes Patellofemoral pain syndrome (chondromalacia patellae) Anterior knee pain No; overuse injury more likely No Typically presents in women as “theater sign”—mild to moderate anterior knee pain, worse after prolonged sitting Iliotibial band tendonitis Lateral knee pain No; overuse injury more likely (repetitive knee flexion) No No effusion Pain aggravated with activity Anterior cruciate ligament sprain General knee pain Yes; noncontact deceleration forces No Immediate onset of moderate to severe joint effusion Swelling within two hours of “pop” Medial collateral ligament sprain Medial joint line pain Yes; misstep or collision No Immediate onset of pain/swelling after trauma Lateral collateral ligament sprain Lateral joint line pain Yes; varus stress No Immediate onset of lateral knee pain Less common than medial collateral ligament sprain Meniscal tear Medial or lateral joint line Yes; sudden twisting injury No Can occur with chronic degenerative process Mild effusion Possible atrophy of the vastus medialis obliquus portion of the quadriceps Catching/locking of the knee Can have positive McMurray test Septic arthritis Generalized extreme pain with any movement No Yes Elevated WBC Elevated ESR (usually > 50 mm/hr) Abrupt onset of pain and swelling Arthrocentesis with turbid synovial fluid Osteoarthritis Generalized or joint line tenderness; pain aggravated by weight-bearing activities, relieved by rest Not acute trauma Past history of trauma can predispose to developing osteoarthritis No Chronic joint stiffness and pain Crepitus on exam Mild or no joint effusion Gout / pseudogout Extreme pain with any movement; also painful to touch No No Acute pain and swelling without prior trauma Arthrocentesis with clear or slightly cloudy synovial fluid Negatively birefringent rods in gout Positively birefringent rhomboids in pseudogout Popliteal (Baker) cyst Posterior popliteal area No No Insidious onset of mild to moderate pain in the popliteal area of the knee Most common synovial cyst of the knee CONTINUE “What brings you in to the office today?” “I’ve been having some pain in my right knee. It’s really been bothering me. It feels achy all over. I’ve had knee pain off and on for months, but it has become more constant in the last two weeks. When the pain didn’t seem to be going away, I decided to come to see the doctor. I am tired of not being able to garden anymore.” “Where is your pain?” “It just seems to be my knee that bothers me. I don’t understand it—it’s not like I’ve injured it or anything. I hit my knees sometimes when I’m gardening, but nothing serious.” “Do you have pain in other joints?” “I sometimes have left knee pain and low back pain, but it seems different from the knee pain I have now. My right wrist acts up on occasion too, but I can talk with you about that another time.” “Can you tell me how severe it is on a scale from 1 to 10, with 10 being the worst pain in your life?” “Right now, my knee pain is about 6 out of 10. Sometimes it seems better than that, and other times worse.” “Does your knee ever lock, pop, or give way?” “Not usually. It sometimes feels like it’s grinding.” “Does anything make the pain better or worse?” “Bengay helps a little. I get heartburn so I haven’t tried any other medicine because I was afraid it would bother my stomach. The pain seems to get better when I rest. It’s not as bad when I wake up in the morning as it is later in the day.” TEACHING POINT Effects of Nonsteroidal Anti-Inflammatory Medications on Gastrointestinal Symptoms Nonsteroidal anti-inflammatory medications, such as ibuprofen (Advil, Motrin), can worsen the symptoms of gastroesophageal reflux disease (GERD), especially if taken on an empty stomach. They also are clearly associated with gastritis and gastrointestinal bleeding, particularly when taken for more than three months. Though NSAIDs are more effective than acetaminophen for treating arthritis pain, these side effects limit their use and make both acetaminophen and NSAIDs first-line options. Selective COX-2 inhibitors (coxibs) were initially promoted as being protective against GI bleeding, but subsequent research has demonstrated that GI bleeding occurs with this subclass of NSAIDs, although at rates lower than those for more commonly used NSAIDs. The rate of GI bleeding for celecoxib is similar to that for diclofenac and is approximately half the rate for ibuprofen and naproxen. This benefit is offset by an increased risk of cardiovascular events (e.g., myocardial infarction) seen with celecoxib and diclofenac compared with naproxen. Conversely, the cardiovascular benefits seen with daily low-dose aspirin use are offset by a 40% increased risk of GI bleeding. A meta-analysis demonstrated that diclofenac 150 mg per day is the most effective NSAID for improving osteoarthritis pain and function, followed by naproxen. A Cochrane review showed that topical diclofenac is moderately effective for chronic musculoskeletal pain Ms. Roman answers the rest of your questions and you find out: Past medical history: History of GERD Remote history of alcohol use disorder Past surgical history: Tonsillectomy as a child and no other surgeries Medications: Multivitamin Extra-strength Tylenol Tums as needed for heartburn No herbal supplements. Review of systems: Normal, except for the right knee pain, occasional left knee pain, intermittent back pain, and occasional heartburn. She reports no fevers, weakness, numbness, or tingling. Family history: Her mother has type 2 diabetes and osteoarthritis, and her dad has “skin problems.” Social history: Doesn’t drink alcohol or smoke. She is a retired teacher and lives alone in a two-story home in a rural community. Her hobbies include gardening and playing with her granddaughter, Lucy, who lives nearby. Since Ms. Roman hasn’t had a drink in years, you decide to skip screening her for alcohol disorders. You thank Ms. Roman for talking with you and excuse yourself while she changes into a gown for her physical exam. You find Dr. Medel and relay Ms. Roman’s story. Then the two of you return to Ms. Roman’s room to perform the physical exam together. CONTINUE Vital signs: Temperature is 37.1 °C (98.8 °F) Pulse is 64 beats/minute Respiratory rate is 18 breaths/minute Blood pressure is 130/80 mmHg No conjunctivitis or apparent skin lesions. The patient favors putting weight on her left knee a little, but she does not have much trouble climbing onto the table. No erythema, edema, bruising, or atrophy of the quadriceps on either leg. Some tenderness to palpation along both the medial and lateral joint lines on the right leg. Range of motion is 120 degrees in her right leg. Some crepitus with motion in the right patella. Small effusion appreciated from milking the right suprapatellar pouch. Right knee joint is slightly warm compared to the left. No fullness in the popliteal fossa. Negative Lachman and McMurray tests. No pain or laxity with varus or valgus stress. Negative anterior and posterior drawer tests. Hip exam is unremarkable, with no tenderness and a normal range of motion. Ankle exam is unremarkable, with no tenderness and normal range of motion. Have the patient put on a gown, as it is important to be able to fully examine and compare the painful knee and the non-painful knee. Observe the patient walking and climbing onto the examination table. Inspect both legs for erythema, edema, bruising, or atrophy of the quadriceps. Palpate the knee joints, feeling for warmth, effusion, and point tenderness. Pay particular attention to the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line. Check knee range of motion by flexing and extending the knees (normal is 0 degrees extension and 135 degrees flexion). Assess for tenderness and range of motion on hip and ankle exam. In general, consider examining the joint above and below the area of concern on the musculoskeletal exam. Ms. Roman is a 74-year-old female who presents with worsening of her chronic right knee pain over the last two weeks. There is no history of trauma, no constitutional symptoms, and no morning stiffness. Physical exam reveals mildly decreased range of motion of the right knee with crepitus and a small effusion and warmth but no erythema and no skin lesions are present. The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes: Epidemiology and risk factors: 74-year-old female with chronic right knee pain Key clinical findings about the present illness using qualifying adjectives and descriptive language: No history of trauma No constitutional symptoms No morning stiffness Decreased range of motion Crepitus Small effusion No erythema No skin lesions QUESTIONS TO ANSWER What is your list of appropriate differential diagnoses and why? What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings. Describe the pathophysiology that may lead up to the final diagnoses. What pharmacology treatment would you recommend and why? SCIENCE HEALTH SCIENCE NURSING NURSING NSG 6023

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