| Case 28 scenario ( knee pain )
Doorway information about patient
The patient is a 53-year-old man who comes to the emergency department due to right knee pain and swelling.
Vital signs
. Temperature ; 38.3¡¦C (101F) . Blood pressure : 130/60/mmHg . Pulse : 80/min . aspirations : 18/min
Basic differential diagnosis
. Osteoarthritis . Septic arthritis and bursitis . Pseudogout and gout . Reactive arthritis . Traumatic knee injury . Lyme disease . Monoarticular rheumatoid arthritis . Psoriatic arthritis
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Case 28 sim.pt. instruction
If the doctor asks you about anything other than these , just say ¡§ no ,¡¨ or provide an answer that a normal patient might give.
You are a 53-year-old man with right knee pain
History of present illness
. 2 days of worsening right knee pain . Throbbing pain , 7/10 severity . No radiation of pain . no relief with ibuprofen . No recent trauma . Chronic bilateral knee pain starting a year ago that is worse with walking and thought to be due to being overweight . Stiffness in multiple joints every morning for 10-15 minute that resolves spontaneously . No other aggravating or relieving factors
Do not volunteer this information unless asked :
Review of systems
. No fever or chills . No nausea , vomiting , diarrhea , or constipation . No rash . No recent travel or sick contacts . No inset bite . No urinary symptoms
Past medical / family / social history
. Hypertension for the past 10 years
. No surgeries or hospitalizations . Medications ; Hydrochlorothiazide 25 mg daily ; ibuprofen 600 mg up to 3 times a day as needed . Medication allergies : None . Father as hypertension and mother has pseudo gout ; no siblings . Occupation : Librarian . Married , live with wife . Tobacco : none . Alcohol ; 1 or 2 beers on social occasions . Recreational drugs ; None
Physical examination
HEENT : . PERRLA , EOMI . No conjunctival abnormalities
Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs
Musculoskeletal : . Right knee is tender to palpation with decreased range of motion but no redness or warmth . no other joint abnormalities
Skin : . No rates or lesions
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Case 28 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the onset of pain . Asked bout the course of pain over time . Asked about the intensity of pain . Asked about the quality of pain . Asked about the location of pain . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Fever - Joint swelling - Joint redness - Rash . Asked about history of trauma to the joint . Asked about morning stiffness . Asked about history of travel (especially areas with endemic Lyme disease) . Asked about any rennet ticks bites . Asked about any pain and swelling in the other joints . Asked about nay recent history of febrile illness . Asked about any eye symptoms
Past medical /family/social history
. Asked about similar episodes in the past or other joint problems . Asked about past medical issue , surgeries , and hospitalizations . Asked about current medications . Asked about medication allergies . Asked about family health (especially joint disorders) . Asked bout tobacco , alcohol , and recreational drug use . Asked about occupation . Asked about living situation and sexual contacts
Examination
. Washed heads before examination . Examined without gown , not through gown . Checked knee for range of motion . Checked other joints for swelling and redness . Auscultated heart . Examined eyes . Examined skin for washed or painful nodules
Counseling
. Explained physical findings and possible diagnosis . Explained further workup
Communication skills and professional conduct
. Knocked before entering the room . introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions
. Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
Differential diagnosis
. Osteoarthritis . Septic arthritis or bursitis . Pseudo gout , gout . Inflammatory (eg, rheumatoid ) arhritis
Diagnostic study/studies
. CBC with differential . Joint aspiration . X-ray of knee . Sedimentation rate or C-reactive protein , antinuclear antibody, rheumatoid factor or cyclic citrullinated peptide antibodies . MRI of joint . Lyme serology (if travel to endemic area)
The following points should be addressed for traumatic knee pain:
. Asked what you were doing at the time of injury . Asked about mechanism of injury . Asked bout any noise or popping sensations at the time of injury . Asked whether you can bear weight and whether the knee is unstable with walking . Asked about locking of joint . Performed Lachman maneuver or drawer test . Performed McMurray maneuver
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Case 28 clinical summary
Clinical Skills Evaluation Case 28 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient¡¦s problem(s).
. 53-yo man with 1 year of bilateral knee pain , now with 2 days of worsening right knee pain described as throbbing and constant . Pain is 7/10 , no relief with ibuprofen . 15-20 minute of morning stiffness in multiple joints each day that resolves spontaneously. . No H/O trauma
ROS : No fever , chills , nausea , vomiting , diarrhea , constipation , rashes , travel history , sick contacts , insect bites , or urinary issue PMHx : HTN for 10 years PSHx : None Meds : Hydrochlorothiazide 25mg daily , ibuprofen 600mg as needed Allergies : None FHx : Father has hypertension ; mother has pseudogout SHx : No smoking , occasional alcohol use
Physical examinations : Describe any positive and negative findings relevant to this patient¡¦s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature , 38.3¡¦C(100.9F); blood pressure , 130/60 mmHg; pulse , 80/min; and respirations , 18/min . HEENT : PERRLA , EOMI , no conjunctival hemorrhage . Heart : RRR without murmurs , gallops , or rubs . Musculoskeletal : Tender right knee , decreased ROM , no swelling or warmth , no other joint deformities . Skin ; No rashes or lesions
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient¡¦s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Osteoarthritis flare
History finding(s) . History of chronic knee pain . Acute worsening of right knee pain
Physical examination finding(s) . Decreased ROM in right knee
Diagnosis #2 : Septic joints
History finding(s) . Acute-onset right knee pain
Physical examination finding(s) . Fever . Decreased ROM in right knee
Diagnosis #3 : Acute crystal arthritis (Gout or pseudogout )
History finding(s) . History of diuretic use . Acute-onset right knee pain . Family history of pseudogout
Physical examination finding(s) . Fever . Decreased ROM in right knee
Diagnostic studies
. Right knee arthrocentesis . Right knee x-ray . ESR . CBC with differential
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