Patient Information:

Patient: X, Age: 15 years old, Sex: Male, Race: Black

S.

CC (chief complaint): patient came for a dull pain in both knees.

HPI: Mr X a 15-year-old, black male who came in for a dull pain in the knee. He said sometimes one or both knees click, with a catching sensation under the patella. I will if the pain is limiting joint movement, the onset of the pain, is the pain intermittent or constant. The pain started having the pain a month ago while he climbed the stairs at home. Slight swelling no redness which sometimes affects both knees which has interrupted with his daily activities. The joint looks good. The patient said pain is experienced with movement and worse with climbing or ascending a flight of stairs as such it most felt during the day while he is active and relieved with rest. His mom applied ice to the knees and gave 500mg of Tylenol which relieved the pain. Mom also applied icy hot rub to help with the pain. The cause is unknown to the patient, but he says he is soccer player and has had contacts with friends in the field while playing so he feels it could be from the trauma in contact sports.

Location: knee- bilateral at times

Onset: insidious

Duration: started a month ago

Character: dull knee pain with one or both knees having a click sensation, with a catching sensation under the patella

Associated signs and symptoms: no fever, no nausea, no vomiting, limited movement, swelling of the knee

Timing: while climbing a flight of stairs or with strenuous activity, or movement.

Exacerbating/ relieving factors: pain is worse with climbing and movement, relieved with rest. Mom applied an ice pack to the knees, used icy hot rub and gave him 500 mg of Tylenol which he said helped. He has been using them for a week now.

Severity: 8/10 pain scale with movement, 3/10 while at rest

Current Medications:

Tylenol 500 mg 1 tab x 2/ day

Ice packs were used as needed

Icy hot- twice daily

Allergies: patient’s mom said he had no food of drug allergies and that he has never had an allergic reaction. The patient also confirmed he has no allergies.

PMHx: up to date with all immunizations. He has never been hospitalized and has had no surgeries. He was born at term with no abnormalities or deformities, patient denies any autoimmune condition.

Soc Hx: Patient is in high school and plays soccer but has been remote leaning and so has not played in about 3 months buts jogs daily around the neighborhood. He lives with his mom and dad and has 2 siblings in their single-family home. Patient has health insurance through his parents and good access to healthcare. His hobby is doing sports; running sprinting and soccer which have been limited with the pain in his knee. He can perform his activities of daily living but unable to complete activities like climbing and bending while performing house chores. He says he gained some weight from staying more at home lately but weight but normal for his age. He eats a balanced diet with fruits and vegetable and Powerade while exercising especially with the morning sun for vitamin D. He rarely drinks sodas. He says he never smoked and does not drink alcohol. He is to club activities in school to keep focused and out of bad companionship. His parents are involved in life to make he succeeds.

Fam Hx: Mom has osteoporosis and has had a knee replacement surgery, Dad is healthy. No medical problems with siblings. Maternal died at 75years from stroke, maternal grand mom is still living. She is 77years and takes just vitamins. Both paternal grandparents are of late, not sure of the cause of death.

ROS:

GENERAL:  no fever, no chills, knee pain, no weight loss.

HEENT:  Eyes:  patient has impaired vision and wear glasses. Hearing is intact, patent nostrils and mouth is pink and moist. No sores in the throat.

SKIN:  No rash or itching, skin is intact

CARDIOVASCULAR:  patient denies chest pain, no palpitation, he has strong pulses on all extremities.

RESPIRATORY:  No shortness of breath, no cough

GASTROINTESTINAL:  denies nausea, vomiting and diarrhea. No pain in the stomach

GENITOURINARY: he voids normally and able to control stream

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  pain in the joint and muscles of the knee, no stiffness, click sound heard with movement, swelling

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes.

PSYCHIATRIC:  patient says he has never been depressed but he is anxious about what is going on with his knee.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  no known allergies

O.

Physical exam:

General: Mr X is a 15-year-old, black and a male who came in accompanied by his mom for a dull knee pain. His dressing is appropriate for weather, alert, oriented, and cooperative with care answering all his questions.

Vital signs: BP 120/70 pulse 65 respiration 20 and regular temperature 97.8F and weighs 110 pounds, height 5’7”

HEENT: head is normocephalic, pupils are equal and reactive to light and accommodation, he wears glasses. No bleeding or drainage from the nares, patent bilaterally, septum in midline position, buccal cavity is pink and moist, no redness with the oropharynx, gums are pink, no inflammation.

NECK: supple, full range of motion, no thyromegaly, no carotid bruits, no masses. Trachea in midline

RESPIRATORY: clear breath sounds in all lung fields, symmetric chest movement.

CARDIOVASCULAR: regular heart sounds and rhythm, distal pulses are +3, no murmur

BREAST: no masses, normal for gender

ABDOMEN: soft, flat, and non-tender, no dullness on percussion, no guarding, active bowel sounds in all 4 quadrants.

RECTAL: non tender, not enlarged prostate- fully developed for age, good anal sphincter tone.

MUSKULOSKELETAL:

Inspection: no erythema, slight swelling, no bruising, knees were symmetrical.

 Palpation: the patella felt smooth and firm, a little swelling below the patellar, pain felt with touching, flexion, and extension. With ballottement, no fluid in the joint, with the bulge sign. McMurray test revealed a click, pain and limitations in extension and flexion both lateral and medial. Varus and valgus test revealed no deformity. Spine is straight, no masses.

Range of motion and strength testing: Patient was unable to complete task there is limited range of motion.

NEUROVASCULAR:  patient is alert and oriented x 4, behavior is appropriate for situation, motor, sensory and deep tendon reflexes 2+ bilaterally for the patellar and Achilles tendons

Diagnostic results:

Plain x-ray to determine if any problem with the kneecap, and the location of the patella (anteroposterior view, lateral view, and Merchant’s view).

Ultrasound of the knee to evaluate mechanical complaints such as ‘clicking’ through palpation with an ultrasound transducer.

MRI- to view soft tissues around the knee and it is used when surgery is indicated (Orthoinfo, (n.d.)).

Lab- to check inflammation such as the erythrocyte sedimentation rate, C-reactive protein and complete blood count if infection is suspected (Bunt & Jonas, 2018).

Differential Diagnoses:

Osgood-Schlatter disease (tibial apophysitis)

This is an insidious onset of knee pain in growing adolescent during their growth with concomitant overuse. It is an inflammation of the area below the knee where patellar tendons attach to the tibia and occurs during growth spurts when the bones and surrounding tissue are rapidly changing forms compounded by the stress but on them by strenuous activities. A common condition in kids who are athletics (Orthoinfo, 2020).

Quadriceps or patellar tendinopathy (Jumper’s knee)

It is an overuse injury that can be painful during activity with pain being the main symptom. The pain is usually below the kneecap and worse with activity like climbing, squatting, and running. Indeed, the pain is with any strenuous activity and persists even after activity (Children’s healthcare of Atlanta, n.d.). This is an anterior pain affecting the patellar tendons (Bunt & Jonas, 2018).

Tendonitis (Tenosynovitis)

It is pain in the front of the knee made worse with climbing. Inflammation of the synovium sheath around the tendon as a result of repeated actions associated with sports or other strenuous knee activity which can result in rheumatoid arthritis. It could also affect the shoulder, wrist, or heel. The patient manifests with pain and tenderness over the involved tendon with movement and some limitation of the affected joint.

Medial collateral ligament (MCL) sprains 

According to the Children’s healthcare of Atlanta (n.d.), it is a sprained medial or lateral collateral ligament (MCL) is a common soccer injury due to direct hit on the knee during a soccer game. There may be “popping” sound in the knee at the time of injury, followed by knee pain on the inner side of the knee. Swelling and knee weakness is possible.

Muscle strain

This can be due to excessive stretching o forceful contraction beyond functional capacity. Given that the patient is a soccer player, it could be from improper exercise too or previous injury from contact in the field of play. It is associated with muscle pain, spasms, and contusion or temporal muscle weakness (Ball, et al., 2019).

References

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

 Bunt, C.W.& Jonas, C.E. (2018). Knee Pain in Adults and Adolescents: The Initial Evaluation. Am Fam Physician,98(9), p 576-585. https://www.aafp.org/afp/2018/1101/p576.html

Chronic knee pain.  https://www.healthline.com/health/chronic-knee-pain

Children’s healthcare of Atlanta (n.d.). https://www.choa.org/en/medical-services/orthopaedics/injury-finder/knee/overuse-injuries#D7E3980D-DD48-452C-83B7-1050D525793A

Orthoinfo (n.d.). Adolescent Anterior Knee Pain. https://orthoinfo.aaos.org/en/diseases–conditions/adolescent-anterior-knee-pain/

Orthoinfo (2020). Osgood-Schlatter Disease (Knee Pain).  https://orthoinfo.aaos.org/en/diseases–conditions/osgood-schlatter-disease-knee-pain/

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.