Advanced Health Assessment and Clinical Diagnosis in Primary Care.
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CC: “Complains of dull pain in both of his knees”
HPI: The 15-year-old Caucasian male complains of dull pain in bilateral knees. Complains of catching under unilateral or both knees. Onset gradual but increasing over time, especially in last two weeks. Dull knee pain and catching sensation behind the right knee cap. Rarely, notices the clicking in the left knee but continues to have less pain. Pain is worse with exercise and activity. Pain eases with rest, elevation and ice. Patient rates the right knee at 8/10 and left knee 6/10
PMI: Tonsillectomy at 5-year-old, Flu vaccination 2019 season, HPV immunization completed 2019, Tetanus 2019, hospitalizations
CURRENT MEDICATIONS: None
SH: RR is a middle school student at Austin Middle School. He plays football and basketball with the school. He is a nonsmoker and his household members are nonsmoking. He does not use alcohol and his father drinks 1-2 drinks/monthly and his mother does not drink. He lives in the house with both his parents. He makes good grades.
GENERAL: no weight loss, no chills, no fever, no fatigue.
CV: Negative for palpitations or flutters, negative for hypertension. No edema noted to bilateral upper extremities. No edema to lower extremities.
GI: No nausea/ vomiting no diarrhea, no stomach pain.
PULMONARY: Denies cough, shortness of breath or labored breath.
MUSCULOSKELETAL: Normal gait, ambulates without assistance or limb.
NEUROLOGICAL: No headaches, dizziness, syncope, paralysis, ataxia, and denies numbness and tingling in the extremities. Denies seizures. Denies trauma.
PSYCHIATRIC: No depression or anxiety
VITALS: BP 120/68, P 86, RR 18, O2% 95%, 5’8”, 140#, BMI 21.3
GENERAL: Patient is a well-nourished 15-year-old Caucasian male. He is pleasant and cooperative. Complains of dull pain to knees. Right>left knee has catching sensation
CV: Heart sounds auscultated S1 and S2, no S3, no murmurs, no gallops noted.
GI: Flat abdomen, Bowel sounds normoactive in all 4 quadrants. No masses palpated.
PULMONARY: Chest symmetrical, unlabored breathing, Clear lung sounds in all fields, Percussion tympanic in all fields.
MUSCULOSKELETAL: Abnormal gait with limp favoring the right. Ambulates without assistance. No neck or back pain. Full ROM. Symmetrical bilateral upper extremities, no joint edema of pain. Full ROM. Full strength bilateral 5/5. Bilateral hip flexion 90 without pain, good strength 5/5. Right knee appears to have +1 edema to lateral aspect of knee and no bruising. Right knee is tender with palpation at the popliteal and tibiofemoral joint. Right knee is negative for the McMurray test. Negative Thessaly test to right knee. Right knee is positive at the Q angle 15 with clicking. Negative leg strength 4/5. Negative Thessaly’s test. Pain is passive and controlled range of motion. The left knee has no edema noted. Left knee has full ROM with pain, negative McMurray’s test, negative Thessaly test. Left knee Q angle at 15 degrees with clicking in knee. The left knee strength is 5/5. Bilateral ankle is symmetrical. Right ankle ROM intact, flexion 20 degrees and extension 45 degrees, strength 5/5. Left ankle ROM intact, flexion 20 degrees and extension 45 degrees, strength 5/5.
NEURO: Bilateral brachioradialis reflexes 2+ expected, bilateral triceps reflex 2+ expected, bilateral patellar reflexes 2+ expected, bilateral Achilles reflex 2+ expected. No clonus noted bilaterally.
DIAGNOSTIC RESULTS: 4-view x-ray of the bilateral knee, MRI of the bilateral knee without contrast as indicated below.
- Patellar tendinopathy “jumper’s knee”-Overuse and overload to the patellar tendon. Gradual onset of pain and then becoming intolerable. Patient’s complain of dull aching pain with clicking or popping of joint (Dains, Baumann, & Schneibel, 2019, p. 21). A goniometer is used to measure the center of the patella to anterior superior iliac spike, the center of patella to tibial tubercle angle > 10 degrees in males and 15 degrees in females indicate tendinopathy (Dains, Baumann, & Schneibel, 2019, p. 21).
- Osgood-Schlatter disease is an overuse injury and traction apophysis (Patel & Villalobos, 2017, p. 194). This disease is seen mostly in adolescent males in the Tanner stage of 2 or 3. Rapid growth and increased physical activity predispose the development of the condition. Localized tenderness and pain with resisted knee extension are an indicator of the disease. 4 view x-rays of the knee are used to diagnose. In an x-ray an ossicle may show in the fragmentation of the tibial tubercle in the patellar tendon.
- Juvenile Osteochondritis Dissecans-Delamination and localized necrosis of the subchondral bone with or without the involvement of the overlying articular cartilage (Patel & Villalobos, 2017, p. 194). Repetitive microtrauma and local bone vascular insufficiency may be the cause. The lesion can be open or closed and stable or unstable (Patel & Villalobos, 2017, p. 194). Clinical signs develop in the late stages. A patient may have pain after exercising and swelling. Testing for Wilson’s sign with the knee flexed at 30 degrees and internally rotated elicits pain. X-rays of both knees are indicated to compare healthy knee with a damaged knee. A 2-view with a tunnel view assists in identifying the lesion. MRI’s assist in determining the instability of the knee, more notable in adult anatomy (Patel & Villalobos, 2017, p. 194).
- Medial Meniscus tear- Patients complain of pain when the McMurray maneuver test and the Thessaly test is performed. The McMurray maneuver is to lay the patient supine and maximally flex knee and hip while externally and internally rotating the tibia with one hand on the distal end of the tibia and other hand palpating joint (Dains, Baumann, & Schneibel, 2019, p.19). The Thessaly test is the patient stands in front of the examiner while holding their arms. The patient stands flat-footed with one leg and flexes other legs up at 90 degrees. The weight-bearing leg is flexed at 10 degrees and the patient rotates on the weight-bearing leg. The test is positive if the pain is recreated while the leg is maneuvering. MRI of the affected knee will confirm this diagnosis.
- Idiopathic anterior knee pain- The patella-femoral pain refers to no specific vague anterior knee pain in adolescents. This condition is the cause of 30% of adolescents’ knee pain and occurs more in females. The condition is caused by malalignment and abnormal tracking of the patella. It affects one or both knees in and the patient complains of the knee locking, catching, or giving way. Examiner assesses abnormal gait, hip asymmetry, increased lumbar lordosis. Pain is created with patellar inhibition or the compression test. Also, the examiner may place with skin marker one dot above the knee, midline, and a few inches below the knee and flex while looking for malalignment. This condition is treated conservatively with strengthening, good mechanics, and muscle control (Patel & Villalobos, 2017, pp. 191-192).
Assessment of the adolescent male with knee pain includes asking if he can determine the exact source of the pain. Questions of the severity, frequency, and length of pain are important. What does the patient do to relieve the pain? Has the patient tried to rest, ice, and anti-inflammatories? Is there a specific injury? Additional testing on knees is the ballottement test for fluid on the knee, anterior and posterior drawer test, and varus and valgus stress test for unstable ligaments (Ball et al., 2019). Measure and compare the size of the limbs assists in diagnosing. Maneuvers, physical examination, and radiological diagnostic studies assist practitioners in finalizing diagnosis, however, the information the patient gives us is just as important.
Ball, J.W., Dains, J.E., Flynn, I. A., Solomon, B.S., & Stewart, R. W. (2019). Musculoskeletal system: Keypoints. In Seidel’s guide to physical examination: An
interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby
Dains, J.E., Baumann, L. C. & Schneibel, P. (2019). Lower Extremity Pain. Advanced Health Assessment and Clinical Diagnosis in Primary Care (6th ed.). St.
Louis, MO: Elsevier Mosby
Patel, D., & Villalobos, A. (2017). Evaluation and management of knee pain in young athletes: overuse injuries of the knee. Translational Pediatrics 6 (3). (pp.
190-198). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5532199/pdf/tp-06-03-190.pdf