Respond to at least two of your colleagues on 2 different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition, and justify your reasoning. Bilateral knee pain discussion response Essay Paper

First Response:
“Response exhibits synthesis, critical thinking, and application to practice settings. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.

Case 3: Knee Pain

Photo Credit: University of Virginia. (n.d.). Normal Knee Anatomy [Photograph]. Retrieved from http://www.med-ed.virginia.edu/courses/rad/ext/7knee/01anatomy.html. Used with permission of University of Virginia.

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?

Episodic/Focused SOAP Note Template

Patient Information:

J.S, age 15, male, Caucasian

S.

CC: “Dull pain in both knees”

HPI: John Smith is a 15-year-old male who has been brought in today by his mother for dull pain in both knees. Pain initially began starting hockey season in December 2021, and was controlled with Ibuprofen and ice, and nearly was absent prior to just starting soccer season. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. Reports currently 2/10 dull pain, and increased to 5/10 dull aching after physical activity that is controlled with PRN Ibuprofen. Patient reports needing Ibuprofen daily in the evening after soccer practice for aching knees. Without other associated symptoms.  Bilateral knee pain discussion response Essay Paper

Current Medications: Children’s multivitamin daily since age 2

Ibuprofen 200 mg, 1-2 tabs every 6-8 hours PRN pain and no more than 4 tabs in 24 hours

Allergies: Denies medication, latex, food, or environmental allergies

PMHx: Frequent ear and throat infections in early elementary

Tonsillectomy age 10 for chronic infections

Soc Hx: Lives in a safe suburb in a single floor house. Parents married and both work out of the house. Patient has a 12 year old younger brother whom he actively plays outside with. Patient is without exposure to secondhand smoke, and denies tobacco, ETOH, or illicit drug use. He reports enjoying seeing his friends at school and sports; actively playing soccer, recently finished hockey season, and enjoying physical play with friends after school. Mother reports routine well-child visits and patient is up to date on immunizations, has own transportation. Mother reports limiting sugary drinks, a balanced diet, and child is a good eater.

Fam Hx: Brother: without hx. Mother: without hx. Father: asthma as a child. Maternal grandmother: bilateral knee replacement. Maternal grandfather: HTN. Paternal grandmother: hip replacement. Paternal grandfather: no known history.

Immunizations: Up to date on immunizations.

Influenza vaccine 10-20-2021

ROS:

GENERAL: Denies weight loss, – fever, -chills, -fatigue.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, or cough. Denies hx asthma.

MUSCULOSKELETAL: Is + for bilateral knee pain, warm to touch with slight non-pitting edema around bilateral knees. Denies other muscle, back pain, joint pain or stiffness.

SKIN: Denies rash or itching.

O.

Physical exam:

Vital signs: T98.6, P76, RR 22, BP 112/72, O2 sat 98%. Wt. 164 lbs, Ht 5’ 10”

General: Pt appears well groomed, well nourished, without noted distress.

Cardiovascular: HRRR, S1 and S2 audible without murmur, rub, clicks, or gallops.

Respiratory: Chest symmetrical, breath sounds clear to auscultation and percussion.

Musculoskeletal: Spine flexion, extension, and lateral bending as expected without discomfort. Hip strength 5/5 without discomfort, symmetrical. Bilateral knees + pain, + tenderness with slight edema, without noted trauma or ecchymosis, without synovitis. Knee strength 5/5 with mild discomfort to resisted active extension of the knee, and tenderness at the tibial tuberosity, without crepitus. Negative McMurray’s maneuver, negative Lachman’s test, negative bulge sign, + patellar grind/click with flexion to bilateral knees. Bilateral ankles inspected without noted abnormality or irregular alignment. Ankle eversion and inversion, and dorsi plantar flexion and extension ROM as expected without discomfort.  Bilateral knee pain discussion response Essay Paper

Diagnostic results: X-ray, Ultrasound, MRI, RH factor, arthrocentesis

Differential Diagnosis:

1.) Osgood Schlatter

2.) Chondromalacia Patellae

3.) Tendonitis

4.) Bursitis

5.) Juvenile idiopathic arthritis (JIA):

1.) Osgood Schlatter: This disease involves tendinitis of the anterior patellar tendon (which the patella is embedded) and associated osteochondrosis of the tubercle of the tibia (McCance, et al., 2019). The disease is more prominent in young male athletes resulting of quad muscles pulling on the growth plate (McCance, et al., 2019). An x-ray would show bony irregularity and fragmentation, mild soft tissue swelling at the patellar tendon site, and possible joint effusion (Jia Hong Lam, et al., 2019). Full extension and flexion will increase pain over the tibial tubercle, with the joint examination of the knee being normal (McCance, et al., 2019). The patient is an adolescent male participating in sports, and physical and subjective findings support this diagnosis. An MRI may be necessary and ordered by a specialist, and a referral to PT is warranted.

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2.) Chondromalacia Patellae: This condition is caused by patella misalignment, trauma, or anatomic anomalies in the patellofemoral joint cartilage (Caglar, et al., 2020). An anteroposterior x-ray may show an ellipsoid sign (changes in the subchondral bone due to cartilage loss) is present and is a cost-effective screen over an MRI study (Caglar, et al., 2020). Patients typically present with anterior knee pain and often describe the pain to be dull rather than a sharp pain (Caglar, et al., 2020). The patient describes the pain as dull and is also an active athlete. Bilateral knee pain and observations listed also support this diagnosis.

3.) Tendonitis: Involves inflammation of the synovium-lined sheath around a tendon with a point of tenderness around the involved tendon that increases with active movement (Ball, et al., 2019). Increased prominence in athletes and people affected often report a dull achy knee that may be associated with a clicking (McClance, et al., 2019). ROM may be limited by pain with a normal joint examination (McClance, et al., 2019). The quadriceps femoris angle will help evaluate the strain placed on the patellofemoral joint and aid in diagnosing painful disorders of the knee. Also, the patient reports a clicking sensation with knee joint extension and flexion. Tenderness is noted over the inferior patellar ligament. Subjective and objective findings support the signs and symptoms of tendonitis. However, it is without associated femoral anteversion or ankle varus, making this diagnosis less likely (recognizing this association is not an absolute).

4.) Prepatellar Bursitis: Prepatellar bursitis is an inflammation of the bursa in the front of the patella. When the bursa becomes irritated and produces too much fluid, the localized swelling increases pressure on adjacent knee structures (Sheth, et al., 2016). Ultrasound will help visualize the bursa, and aspiration may be used as treatment and laboratory findings for crystals or infection (Sheth, et al., 2016). An MRI is often not needed unless differential diagnoses need to be evaluated. The patients’ subjective findings support this diagnosis; however, minimal swelling noted with pain primarily over the tibial tubercle make this diagnosis less likely. Bilateral knee pain discussion response Essay Paper

5.) Juvenile idiopathic arthritis (JIA): The clinical manifestations differ from an adult, such as; the onset may of arthritis may be fewer than five joints and predominantly affects large joints (McCance, et al., 2019). In JIA, systemic signs of inflammation and generalized headaches are not typical as they are in adult RA (McCance, et al., 2019). The knee joint is also the first and most commonly affected joint by JIA (Hemke, et al., 2018). The MRI is considered the standard to visualize bone marrow and structural abnormalities affected by JIA fully. Lab studies may include an ESR, CRP, CBC, and urinalysis if systemic symptoms are present (Hemke, et al., 2018). Obtaining an RH factor and an arthrocentesis offer specific data when diagnosing JIA (McCance, et al., 2019). The patient has increased pain during and after exercise. Also, the knees are not warm to the touch and are without other associated symptoms. Therefore, this diagnosis will be the least likely given subjective and objective findings.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Musculoskeletal system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Çaglar, S., & Albay, C. (2020). Can Ellipsoid Sign be One of the Earliest Findings of the Medial Femoral Condyle Chondromalacia of Knee Antero Posterior X-Ray?. Indian journal of orthopaedics, 54(4), 518–525. https://doi.org/10.1007/s43465-020-00140-4

Hemke, R., Tzaribachev, N., Barendregt, A. M., Merlijn van den Berg, J., Doria, A. S., & Maas, M. (2018). Imaging of the knee in juvenile idiopathic arthritis. Pediatric Radiology, 48(6), 818–827. https://doi.org/10.1007/s00247-017-4015-

Jia Hong Lam, J., Venkatesh, S. H., Chi Long Ho, Wong, B. S. S., Lam, J. J. H., & Ho, C. L. (2019). Clinics in diagnostic imaging (202). Osgood-Schlatter disease (OSD). Singapore Medical Journal, 60(12), 610–615. https://doi.org/10.11622/smedj.2019160

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.

Sheth, Neil P. MD, Jared R.H. Foran, MD. (2016). Prepatellar (kneecap) bursitis. American Academy of Orthopedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=a00338. Accessed

Bilateral knee pain discussion response

Conducting a further assessment of the patient’s health condition will play a vital role in guaranteeing a successful diagnosis. A meniscal tear of the knee can be tested through the McMurray test. The anterior cruciate ligament can further be assessed through posterior and anterior drawer tests. The presence of lubricating fluid in the knee can also be assessed through ballottement (Castori et al., 2017). Some other laboratory tests that I would consider include erythrocyte sedimentation rate assessment and a blood count. The two lab tests in knee assessment helps to determine the pain of the knee, knee warmth and tenderness whose presence indicates Arthritis. Further lab tests should also be conducted to the knee fluid. Further fractures or deformities can also be assessed through a radiograph. Bilateral knee pain discussion response Essay Paper

Differential diagnosis

• Prepatellar Bursitis is the first diagnosis of consideration. It is a condition that develops when the fluid within the knee is infected by some viruses or bacteria (Castori et al., 2017). The infection can however from other infested body parts through the blood stream. John Smith would likely be suffering from the disease since he suffers from its symptoms such as swelling, pain, fatigue and warmth. I would however reject the diagnosis since the clicking sound experienced by the patient is not a sign associated with the disease.
• Chondromalacia Patellae is the second diagnosis of consideration. It is a condition attributed to pain in the knee cap and the entire knee. It mostly develops when one experiences a fall overuse of knee joint (Lee et al., 2017). The condition develops more often in athletes. Some of its symptoms include a dull knee pain. I would however reject the diagnosis since it does not account for the clicking sound felt by the patient. It also does not account for the progressive pain of the patient after engaging in physical activity.
• Osgood Schlatter. It is an inflammation of the anterior tendon of the patellar (Castori et al., 2017). It is mostly attributed to osteochondrosis and is more pronounced in young male athletes. The catching sensation under the patella and pain symptoms made me consider the condition. Some of its major symptoms include tenderness, inflammation and pain in the knee. I would however accept the diagnosis since the exact symptoms such as knee pain, swelling of the knee and a clicking sound are some of the symptoms of the disease.
• Juvenile idiopathic arthritis (JIA) is also a possible diagnosis of the patient. I agree with you that it is mostly manifested in children despite revealing in adults as well. Some of the major signs include an onset of arthritis in adults and intermittent headaches. The increased pain during and after diagnosis is a possible sign in which the patient also suffers. However, the Patellar Tracking Disorder also manifests through the same symptoms. It develops when an injury occurs making the knee cap to move out of the leg. A person who has the disease experiences abnormal movements of kneecap. Some of its symptoms include a progressively increasing pain during physical exercise, collapsing knee feeling, and popping sounds when walking (Lee et al., 2017). I would therefore reject the diagnosis since it is more similar to Patellar Tracking disorder.
• Tendonitis is the other diagnosis of consideration. It is a condition that involves synovial fluid inflammation around the tendons as you have stated. Most people suffering from the condition are those participating in athletics and have higher chances of developing the disease. Some of the other causes that trigger the disease include a blow directly on the knee cap, weak quadriceps and hamstrings and imbalances of the muscles between the abductors (Lee et al., 2017). Grinding sensation and knee pain are some of its pronounced symptoms. The knee pain and knee clicks made me choose the disease. I would however reject the diagnosis since it does not account to the swelling of the knee.

Joint pain is one health problem that can originate from diverse problems such as neurologic, muscular and skeletal. However, most joint problems are as a result of injuries and infections. When cartilages in the patella are damaged different knee complications develop (Lee et al., 2017). Complications can also be as a result of the infections associated with fluid buildup in the knee. The Osgood Schlatter disorder is the most possible disorder that John Smith is suffering because of experiencing the signs such as knee pain and cracking sound that are attributed to the disorder.

References

Castori, M., Tinkle, B., Levy, H., Grahame, R., Malfait, F., & Hakim, A. (2017, March). A

framework for the classification of joint hypermobility and related conditions.

In American Journal of Medical Genetics Part C: Seminars in Medical Genetics (Vol.

175, No. 1, pp. 148-157). https://doi.org/10.1002/ajmg.c.31539

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(01), e9-e16. https://DOI: 10.1055/s-0037-1598047

Bilateral knee pain discussion response Essay Paper