Knee Pain in Adolescents
Case No 3: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella.
In determining the causes of the knee pain, what additional history do you need? What categories can you use to differentiate knee pain? What are your specific differential diagnoses for knee pain? What physical examination will you perform? What anatomic structures are you assessing as part of the physical examination? What special maneuvers will you perform?
Discussion posts should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style Discussion posting format.
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
- Consider what history would be necessary to collect from the patient in the case study you were assigned.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis?
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
SAMPLE SOLUTION
Patient Information:
Initials: P.A. Age: 15 years Sex: Male Race: White
S
CC (chief complaint): “I have a dull pain in both knees. Sometimes one or both knees click. I feel a catching sensation under the patella.”
HPI: P.A. is a 15-year-old male who has reported to the clinic unaccompanied. His chief complaint is a dull pain in both knees. As reported by P.A., sometimes one or both knees click, and he feels a catching sensation under the patella. The pain started 4 days ago after completing an athletics competition. It increases during activity and subsides during rest. P.A. denies using any medications to manage the pain.
Location: both knees
Onset: 4 days ago
Character: dull
Associated signs and symptoms: fever
Timing: after sitting down for a long time
Exacerbating/ relieving factors: aggravated by physical activity and subsides with rest
Severity: 5/10 pain scale
Current Medications: None
Allergies: No known drug or food allergies reported.
PMHx: Received all childhood immunizations as scheduled. Last tetanus vaccine was on 02/08/2022. Denies a history of hospitalization.
Soc Hx: P.A. is a high school student. He does no consume alcohol or cigarettes. P.A. is an aspiring athlete and like to train everyday with his colleagues.
Fam Hx: No family member has recently been diagnosed with a serious medical condition.
ROS:
GENERAL: Reports fever. Denies abnormal changes in weight. Does not report chills or fatigue. Reports weakness in the knee joints.
HEENT:
Eyes: Denies visual loss or blurred vision
Ears: Denies ear pain
Nose: Denies nasal congestion or stuffiness
Throat: Denies a sore throat
SKIN: Denies itchiness, rashes, or lesions. rash or itching.
CARDIOVASCULAR: Denies chest discomfort or pain.
RESPIRATORY: Denies shortness of cough, sputum, or shortness of breath.
GASTROINTESTINAL: No abdominal pain or discomfort reported.
GENITOURINARY: Does not report a burning sensation during urination.
NEUROLOGICAL: Denies headache or dizziness. Does not report numbness or tingling of the extremities.
MUSCULOSKELETAL: Reports a dull pain on both knees. One or both knees sometimes click. P.A. reports a catching sensation under the patella.
HEMATOLOGIC: Does not report anemia or uncontrolled bleeding.
LYMPHATICS: Does not report enlarged nodes.
PSYCHIATRIC: Denies depression or anxiety.
ENDOCRINOLOGIC: Denies abnormal night sweats. Denies polyuria or nocturia.
ALLERGIES: Denies food or drug allergies.
O.
Vital signs: Temperature: 36.5 degree Celcius, blood pressure: 118/76, respiratory rate: 20 breaths per minute, weight: 124.4 lb, height: 68.2 inches.
General appearance: P.A.is attentive. He is well groomed. He is also properly oriented to time, place, and person.
Skin: No lesions or sores. The skin is warm and hairy.
HEENT:
Head: Normocephalic. No masses. No sign of physical injury.
Eyes: Clear conjunctivae. Visual acuity is 20/20.
Ears: No discharge. No signs of blockage.
Nose: Absence of nasal tenderness. The nasal mucosa is moist and hairy.
Throat: Non-erythematous. No edema or exudates.
Neck: No signs of swelling or pain.
Chest: Rhonchi rubs or wheezes absent
Heart: No gallop. No murmur. Capillary refill less than 3 seconds.
Abdomen: No evidence of abdominal tenderness. Absence of bowel sounds.
Back/spine: No evidence of deformities.
Extremities: Mild pain in the knee joints.
Genitalia/Rectal: Male genital organs present.
Neurologic: Abnormal gait.
Diagnostic results: No tests have been conducted so far.
A.
Differential Diagnoses
- Patellofemoral Pain Syndrome (Runner’s Knee)-Primary diagnosis
- Chondromalacia patellae
- Patellar tendinopathy
- Osteochondritis
- Anterior knee pain
References
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Gaitonde, D., Ericksen, A., & Robbins, R. (2019). Patellofemoral Pain Syndrome. American Family Physician, 99(2), 88-94. https://www.aafp.org/pubs/afp/issues/2019/0115/p88.html
Johns Hopkins Medicine. (2022). Patellofemoral Pain Syndrome (Runner’s Knee). https://www.hopkinsmedicine.org/health/conditions-and-diseases/patellofemoral-pain-syndrome-runners-knee