HPI: M.R. is a 15-year-old Asian male who presents to the clinic today with a chief complaint of pain in bilateral knees.
Initials: M.R Age: 15 Sex: Male Race: Asian
CC: pain in both knees
HPI: M.R. is a 15-year-old Asian male who presents to the clinic today with a chief complaint of pain in bilateral knees. The patient reported the pain had been on and off for the past two weeks on a scale of 5/10. The pain got worse, which led him to stop playing basketball, and he was worried he would not be able to play in the finals. The patient reports that he feels a catching sensation under the patella. The pain is worst when he uses the stairs and stands up from a sitting position. He takes OTC Advil 200mg 2-3 times a day which helps, but the pain is not totally gone.
Current Medications: Advil 200mg PO 2-3x/day as needed for pain
Allergies: NKDA
PMH: Childhood vaccines up to date, Influenza vaccine– 11/2021. Denies any major or serious injury. Denies any surgical procedure. Denies hospitalization.Soc Hx: Patient lives with mom and dad with two younger sisters. He is currently in 9th grade and a member of the basketball team. He loves to surf and play with his siblings.
Fam Hx:
- Mother- HTN, hyperlipidemia
- Father- HTN, hyperlipidemia, hyperthyroidism
- Sister/s- no health issues
- Maternal grandmother- diabetes, hyperlipidemia
- Maternal grandfather- COPD
- Paternal grandmother- Alzheimer’s Disease
- Paternal grandfather- HTN, hyperlipidemia, diabetes
ROS:
GENERAL: Denies weight loss. Denies fatigue. Denies fever or chills.
HEENT: Denies headache. Denies changes in vision or blurred vision. Wears contact lenses. Denies hearing loss and earache. Denies congestion, runny nose, or nose bleeds. Denies sore throat. Denies difficulty in swallowing.
SKIN: Denies rashes and itching. Denies lesions.
CARDIOVASCULAR: Denies any chest pain or discomfort. Denies palpitations. Denies swelling or edema.
RESPIRATORY: Denies shortness of breath or any difficulty of breathing. Denies cough.
GASTROINTESTINAL: Denies any abdominal pain. Denies any vomiting. Denies constipation or diarrhea.
GENITOURINARY: Denies any pain or discomfort when urinating.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, and ataxia.
MUSCULOSKELETAL: Complains of bilateral knee pain. Complains of pain in the bilateral knee when using the stairs and when standing from a sitting position. Complains of tenderness in joint line to bilateral knees. Denies any weakness.
HEMATOLOGIC: Denies any bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies depression or anxiety.
ENDOCRINOLOGIC: Denies heat or cold intolerance. Denies polyuria or polydipsia.
Physical exam:
VS: Ht. 5’7”, Wt. 152 lbs., BMI. 23.8, Temp. 98.8, R.19, P. 88, BP. 100/60 right arm, O2 Sats 99%
General: The patient is well-developed, well-nourished, wearing appropriate clothing, and very pleasant. Alert and oriented, answers questions appropriately and cooperative. The patient follows the command. Noticed the patient rubbing both knees multiple times.
HEENT: Head normocephalic, atraumatic. PERRLA. External auditory canals were patent, and no swelling or drainage was noted. Bilateral tympanic membrane intact without erythema or effusion noted. Nares patent bilaterally. No polyps noted, nasal mucosa pink without rhinorrhea. No sinus tenderness. The oral mucosa is pink and moist.
Neck: Supple, full range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation was noted. No neck pain or stiffness.
Skin: No rashes or lesions noted.
Respiratory: Bilateral lungs clear to auscultation. No SOB was noted or respiratory distress. Breathing unlabored.
Cardiovascular: Normal S1 and S2. Mo murmurs. Rhythm regular. No peripheral edema, cyanosis, nor pallor was noted. Extremities are warm and well perfused without clubbing, cyanosis, or edema. Capillary refill is less than 2 seconds.
Abdomen: Bowel sounds are present in all quadrants. Soft, non-tender, no distention noted. No masses or organomegaly were noted. No guarding or rebound tenderness was noted.
Musculoskeletal: Full ROM in upper extremities. Limited ROM noted in bilateral lower extremities. Popping and clicking sounds were noted with bilateral flexion of the knees. Tenderness was noted during examination when pressure was applied. Pain was noted during squatting and standing. No swelling was noted to bilateral knees.
Neurological: Alert and oriented x 3. Follows command, cooperative. Speech is normal. Normal strength and tone in all muscles. No gross focal, motor, or sensory deficits.
Diagnostic results: Xray of bilateral knees, MRI of bilateral knees
Differential Diagnoses:
- Meniscal Tear
- Patellar Tendonitis
- Bursitis
- ACL Tear
- Patellar Fracture
Assessing Musculoskeletal Pain
Knee pain in teens results from various reasons, including overuse, specific knee injury, or other medical conditions. According to Ball et al. (2019) an acute incident or overuse and repetitive trauma can result in injuries in the muscles, bones, and supportive joint structures. In the scenario provided, in order to diagnose knee pain and knee injury, a thorough history and physical is imperative. The patient should provide when the onset of pain started, what the patient was doing when the pain started and additional information, including frequency, severity, aggravating and relieving factors.
Meniscal Tear
Physical assessment of meniscal tear includes joint line tenderness, swelling, effusions, and a positive meniscus-specific test (Vinagre et al., 2022). In addition, depending on the type of tear and injury characteristics, intermittent catching, snapping, locking, or instability may be present. The authors noted that sports-related injuries such as soccer, football, basketball, skiing, and wrestling are associated with risk factors for meniscal tear. Other risk factors include higher body mass index, delayed reconstruction of Acute cruciate ligament (ACL), and Asian children having a higher prevalence of discoid meniscus. For the young population, MRI has a lower sensitivity and specificity for detecting meniscal injuries. MRI can diagnose discoid meniscus when three or more consecutive sagittal sections demonstrate a continuity of the meniscus between the anterior and posterior horns (Vinagre et al., 2022).
Patellar Tendonitis
Cincinnati Children’s (n.d.) defines patellar tendonitis, also called “jumper’s knee”, as an inflammation of the patellar tendon related to jumping motion, usually in athletes. The signs and symptoms include pain in the front surface of the knee, the area over the tendon is tender, and it may be swollen. With no specific injury, patellar tendonitis can happen over time. The pain usually happens at the start of exercise and can happen during actions like standing, sitting for a long time, or using the stairs. An X-ray is ordered by the healthcare provider to rule out any other bone fracture.
Bursitis
Prepatellar bursitis is caused by pressure from constant kneeling, a direct blow to the front knee, and to athletes who participate in sports such as football, basketball, and wrestling. It can also be caused by a bacterial infection (AAOS, 2022). Healthcare providers will ask the patient the severity, the onset, and how long the patient had symptoms of pain and discuss the risk factors of pain. Usually, x-rays are ordered to rule out any fracture and have a clear picture of the bone. Bursitis is usually diagnosed in physical examination, but MRI may be ordered to check for other soft tissue injuries. According to AAOS (2022) Symptoms of bursitis includes pain with activity, but not usually at night. Rapid swelling on the kneecap, tenderness, and warmth to touch of the affected site. The presence of fever and chills and redness may be caused by infection.
ACL Tear
According to John Hopkins Medicine (n.d.) a sudden pivoting or cutting maneuver during football, basketball, and soccer can injure or tear the ACL. A popping or a snapping sound can be felt or heard at the time of injury, and immediate swelling of the knee develops within the first several hours, and the swelling can be limited if ice is applied to the knee. An X-ray is ordered to rule out any fracture to the bone. An MRI is also beneficial to clarify ACL tear if the information provided by the patient is inconclusive.
Patellar Fracture
A fractured kneecap “patella” is caused by a direct blow to the front of the knee from a car accident or a sporting injury and a fall onto the concrete (Cedars Sinai, n.d.). An X-ray is ordered to take pictures of the knee from several angles to determine the extent of the injury. In a patellar fracture, swelling and a deformed appearance of the knee are visible. The patient usually has difficulty extending the leg, and severe pain is experienced when moving the knee in different directions. When applying pressure to the kneecap, tenderness is noted by the healthcare provider.
Conclusion
In conclusion, an accurate diagnosis of knee pain requires specific physical examination skills. A thorough history must include characteristics of the patient’s pain, mechanical symptoms such as locking, popping, or the feeling of giving away. The timing and the mechanisms of the injury are also important in assessing the knee. Careful inspection of the knee must be included in the physical inspection. The palpation for tenderness, assessment of joint effusion, and the testing of range-of-motion are all beneficial for the appropriate diagnosis of knee pain. If an injury is suspected, radiographs should be obtained to rule out any other fracture and to clarify the disease.
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