| | 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
—————
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
—————
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
—————
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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2018/09/13 07:53am 
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