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 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

¡X¡X¡X¡X¡X

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

¡X¡X¡X¡X¡X

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

¡X¡X¡X¡X¡X

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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