(Please respond to this post, and also add or suggest 4-5 differential diagnosis as well as treatment pan or diagnostic exam. Thank YOU! USE at least 2-3 references)
Review of Case Study # 3. Knee Pain
Patient information: J.J, 15 years old, black male
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Chief Complaint (CC): “Dull pain in both knees” sometimes “one or both knees click” and “a catching sensation under the patella”
Additional History Needed
J.J is a 15-year-old black adolescent male, who presents to the clinic accompanied by his mother complaining of “dull pain” to bilateral knees. He states, “sometimes one or both knees click” and “I get a catching sensation under the patella”. I would want to know how long he has had these symptoms; this would me help in knowing whether his condition is acute or chronic.
I would also assess the severity of his pain. How much does he rate it on a scale of 0-10? He rates his pain as a 4 on a scale of 0-10. Does he have any other accompanying symptoms such as fever? This would help me in ruling out an infectious process. He denies other symptoms. Does he have pain in any other areas? Sometimes back pain can radiate to the lower extremities. Does anything make the pain better or worse? The pain could be due to joint overuse and resting for some time could help manage the condition. Has he taken any medications to control the symptoms? He denies taking any medications today. Does he have any chronic knee illnesses, or has he sustained previous injuries to the knees? The pain could be related to previous pathology on the knees. He denies any chronic knee diseases or previous injuries to the knee.
· Current Medications: Mother gives him Tylenol unknown dose for pain as needed every 6 hours, he denies the use of vitamins, herbal treatment or other complementary therapy
· Allergies: J.J reports no medication, food, environmental, or latex allergies.
· Past medical history (PMH): He denies any past medical history, previous hospitalizations or surgeries
· Immunization history: All his childhood immunizations are up-to date
· Family history: His mother is healthy; his father has hypertension. He has 2 sisters who are healthy. Both paternal and maternal grandparents are alive and healthy.
· Social history: J.J is in 6th grade. He lives with his parents and his 2 sisters. He denies exposure to 2nd hand smoke, he is an active boy and plays in his school basketball and football team. During the weekend he plays at a neighborhood park with his friends. He has a great social support from his family and friends. at home. His parents take care of him and provide for all his needs. He denies having trouble affording necessities.
Review of Systems
- Constitutional: J.J sits on the examination table; he is not in distress and is a good historian. He reports a 10lbs weight gain in the last 2 years, he denies fever, chills or difficulty sleeping.
- Skin: He denies any dryness, redness, rashes, or any injuries
- Cardiovascular: He denies chest pain, chest pressure, chest discomfort or palpitations.
- Respiratory: He denies shortness of breath, cough, or sputum.
- Hematologic: No anemia, bleeding, or bruising reported
- Neurovascular: He denies any decrease in sensations to bilateral (BL) upper and lower extremities or any other body parts.
- Musculoskeletal: He reports dull pain, clicking and a catching sensation to BL Knees. He also reports pain going up or downstairs. He denies joint stiffness, back pain or any other musculoskeletal pain.
- Extremities: Capillary refill time less than 2 seconds to BL extremities toenails and fingernails.
· Vital signs: blood pressure: 115/65 mmHg, pulse 80b/min Respirations: 18/min, SPO2: 100%, Temperature: 98 F
· General: J.J is alert, cooperative and not in acute distress, slightly limping on his left knee as he walked in.
· Integumentary: skin pink, warm and moist, no pallor or cyanosis noted.
· Cardiovascular:S1 and S2 sound heard on auscultation, No heart murmurs or extra sounds noted. The point of maximal impulse is 80b/min, no peripheral edema or varicosities noted, central pulses present, pulses+2 bilateral pedal, and +2 radial.
· Respiratory: On assessment, chest is symmetrical with no accessory muscle use. Chest clear to auscultation anterior-posterior and lateral. No bruits heard on percussion
· Neurovascular: BL lower extremities warm, no numbness, tingling, or pins and needles sensation no decreased extremity movement noted on testing range of motion, mild pain reported to BL knees
· Musculoskeletal: On inspection of BL knees and popliteal spaces, medial side of the left knee noted to be concave. BL knee joints have full range of motion. On ballottement of BL knees, clicking sensation appreciated. On palpation of joint space clicking sound appreciated to BL knees. Strength of muscles equal on flexion and extension. No torn medial or lateral meniscus noted on performing the McMurray test. No instability of the anterior and posterior cruciate ligaments noted on performing the drawer test.
Diagnostic Tests for Knee Pain
As noted by Ng, Price and Deepak (2019), Diagnostic tests for knee pain include X-ray examination of the intercondylar notch views. The x-ray usually shows any lesions present in the knee effectively. It should be done both anteroposterior and lateral.
Magnetic resonance imaging (MRI) or ultrasound are also effective in showing extent of the lesions, any inflammation and the integrity of the overlying articular cartilage (Ng et al. 2019).
As recommended by Ng et al. (2019), blood tests such as complete blood count and tumor markers should be done to check for both chronic and acute infections as well as a raise in inflammatory markers to rule out tumors such as osteosarcoma.
Differential Diagnosis for Knee Pain
· patellofemoral pain syndrome (PFP): As explained by Rathleff, M. S., Rathleff, C. R., Olesen, Rasmussen and Roos (2016) patellofemoral pain syndrome (PFP) affects about 7% of adolescents. It is normally caused by injury especially during sports or joint overuse. Pain is normally vague and is usually activity related. It’s common in adolescents affecting about 30% of the adolescents. Knee effusion is common in PFP Ball, Dains, Flynn, Solomon and Stewart (2019). Pain is also aggravated by activity such as using stairs or squatting, patients may also have an abnormal gait, or asymmetry of lower extremities on examination (Patel &Villalobos 2017).
· Osgood-Schlatter disease (OSD). As noted by Green, Sidharthan, Schlichte, Aitchison, and Mintz (2020), OSD is usually caused by repetitive strain and chronic avulsion from the patellar tendon, the pain is usually localized and bilateral in 20-30% of the patients (Patel & Villalobos 2017), this is a possible diagnosis for a 15 year old adolescent patient due to joint overuse.
· Juvenile osteochondritis dissecans (JOCD) As explained by Patel and Villalobos (2017) JOCD is one of the main causes of knee pain in adolescents. It can occur in both active and non-active adolescents. It is characterized by delamination and local and local necrosis of the subchondral bone. Overlying articular cartilage may or may not be involved. Exact cause is unknown, but it’s thought to be caused by repetitive microtrauma to the bone and cartilage. The pain is usually gradual over a couple of days to weeks and is made worse by activity. Examination may reveal mild effusion or limited ROM. Usually diagnosed by X-rays AP/ lateral.
· Illial- tibial band (ITB) friction syndrome. ITB syndrome is an overuse syndrome affecting the tendon as is it passes over the lateral femoral condyle. Repeated friction between the ITB and the lateral femoral condyle causes chronic inflammation and pain during activity. It is the most common cause of lateral knee pain in runners but has been reported in other sports such as skiing football and soccer (Patel & Villalobos 2017). The patient in our case scenario is an active adolescent who plays football in school. This is a likely diagnosis for him.
· Septic arthritis (SA) As explained by Pääkkönen (2017), septic arthritis in children is hematogenous and it affects large joints of the lower extremities such as the knee joint. It is mostly caused by Staphylococcus aureus which can be isolated in blood cultures. It usually occurs as a result of slow blood flow in the metaphyseal capillaries predisposing the growing bones to hematogenous seeding from any trauma or infection. The patient in the case scenario may have had prior knee infection or trauma.
Primary Diagnosis: patellofemoral pain syndrome (PFP)
As recommended by Patel and Villalobos (2017), conservative management with rest and modification of activities is normally effective. Short-term non- steroidal anti-inflammatory medications can also be prescribed. I would:
- prescribe Naprosyn 500mg twice daily as need for pain
- Advice patient to continue with activity as tolerated
- Avoid activities that aggravate the pain such as going upstairs or squatting
- Refer patient for rehabilitation exercises to improve strength, endurance and flexibility of the knee muscles.
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