Bilateral Dull Knee Pain Discussion
Subjective
CC: Patient AA complains of bilateral dull knee pain with a “catching” sensation under the patella or kneecap. This is accompanied by occasional clicking on both knees.
History of Presenting Illness (HPI): Patient AA denies any previous history of the above symptoms at any given time. The time of onset of the symptoms was one week ago and without any history of trauma. The location of the pain is the knees, specifically in the area under the kneecap. It lasts for several minutes at a time intermittently, approximately five minutes. The most outstanding characteristic of the pain is that it is dull. The pain is made worse or aggravated by ambulation/ locomotion from one place to another. It is however temporarily relieved by OTC Tylenol taken as 1 g prn. The time that the pain is more noticeable is in the morning when waking up. On a scale of 1-10, patient AA rates his pain at 5/10.Bilateral Dull Knee Pain Discussion
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Current Medications: He is currently taking Tylenol 1 g prn when he experiences pain in the knee. This is OC non-prescription medication.
Allergies: He denies any allergies to medication, food, or environmental substances.
Past Medical/ Surgical History: Admits to being admitted to the hospital twice for pneumonia in 2012 and again in 2015. He denies having undergone any surgical procedures.
Social History: Patient A is still a student and a dependant. He lives with his family comprising of his father, his mother, and a younger sibling who is sister. They live in a middle class neighborhood with all amenities and recreational facilities. None of his parents either drinks or smokes. The parents never use a phone when driving and they always fasten their seatbelts on before setting out in the family care.
Family History: The parents do not have any chronic lifestyle diseases such as diabetes, hypertension, or heart disease. There is also no history of chronic illnesses on the side of the maternal grandparents. Both maternal and paternal grandparents are still alive. The paternal grandfather is suffering from type II diabetes mellitus and hypertension.
Review of Systems (ROS)
General: He denies malaise, fever, weakness, or fatigue.
HEENT: He has no double vision and also denies blurring of vision. He denies ear discharge, ear pain, or tinnitus. There is no nasal discharge or sneezing and the throat is not sore.
Integumentary: He denies any rashes or itching as well as allergic dermatitis.
Gastrointestinal: He denies having nausea, vomiting, constipation, or diarrhea. He reports regular bowel movements with the last one being at the hospital.
Cardiovascular: He denies having cold or pale extremities. He also denies ever having chest pain, palpitations, or syncope.
Respiratory: He denies having any cough or difficulty in breathing.Bilateral Dull Knee Pain Discussion
Genitourinary: He denies pain or burning sensation during micturition.
Neurological: He denies ever having any fainting attacks. Also denies having paraesthesia or gait changes. His bladder and bowel control are still intact.
Musculoskeletal: Admits to having dull knee pain bilaterally and occasionally hearing a “clicking” sound from the knees. Also admits some degree of stiffness of the knee joint bilaterally. Denies back pain.
Endocrinologic: He denies passing excessive volumes of urine or drinking a lot of water. He also denies ever sweating excessively or suffering heat intolerance.
Lymphatics: He has never undergone splenectomy and denies having any enlarged palpable nodes.
Hematologic: He denies getting spontaneous bruises, having unusual palor of the body, or experiencing dizziness.
Psychiatric: He denies any history of mental illness such as depression.
Allergic/ Immunologic: He denies suffering from asthma or food/ drug allergies.
Objective
General: Patient AA is well-nourished and is appropriately dressed for the weather. He is alert and oriented in time, space, place, and person. His vital signs are T: 37.2°C; BP: 120/75 mmHg; RR: 15/ min; P: 78 b/m.
Head: Atraumatic and normocephalic.
EENT: No otorrhea, no nasal polyps or rhinorrhea, and no throat exudate. Pupils are equal, round, and reactive to light and accommodation (PERRLA).Bilateral Dull Knee Pain Discussion
Skin: Flawless with no rashes. Sufficient elasticity and turgidity.
Musculoskeletal System: Pain and tenderness on the knee joint bilaterally on palpation and manipulation. Limited flexion and extension with some degree of guarding. Milking of the suprapatellar pouch when the patient is supine and the knee is extended did not show evidence of an effusion. Palpation of the patella yielded no crepitus. Measurement of the quadriceps angle (Q angle) shows that it is about 17%. Patellar apprehension test is also positive. The anterior drawer test and Lachman test are both negative (Bickley, 2017; Bunt et al., 2018).
Diagnostic tests: Patellar apprehension test, Lachman test, anterior drawer test, pivot shift test, McMurray test, Ballottement test, Thessaly test, and bilateral knee X-rays. Laboratory tests done were C-reactive protein and rheumatoid factor (Bunt et al., 2018). The patellar apprehension test was positive but all the other tests were either negative or did not show any proof of a fracture, cruciate ligament injury, or torn meniscus.
Assessment
The five possible differential diagnoses according to the history, physical examination, and tests are as follows:
- Lateral subluxation of the patella
This is the most likely diagnosis for this adolescent. This is because the tests done during the physical examination lean towards the diagnosis. The patellar apprehension test which specifically tests for patellar subluxation was positive. The diagnosis was reinforced by the finding that the Q angle was above 15%. A Q angle above 15% predisposes to subluxation of the patella when it is pulled by the quadriceps muscle (Bunt et al., 2018; Gemas, 2015).
- Medial plica syndrome
This diagnosis is also feasible as it is may caused mechanical symptoms such as catching and clicking. Tenderness is also present (Bunt et al., 2018). Patient AA reported catching and clicking and also demonstrated tenderness on palpation bilaterally.
- Collateral ligament sprain
It causes medial or lateral pain. On physical examination, the patient feels pain with applied force (Bunt et al., 2018; Bickley, 2017).
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- Sinding- Larsen-Johannson syndrome (distal patellar apophysitis)
It usually affects adolescents who are 10 to 13 years of age. On physical examination there is some degree of tenderness on the inferior patellar pole (Bunt et al., 2018). Bilateral Dull Knee Pain Discussion
- Osgood-Schlatter disease (tibial apophysitis)
It commonly affects adolescents and is linked to the normal developmental growth spurt seen at that stage. It is normally atraumatic with the tenderness experienced being located more at the tibial tubercle (Bunt et al., 2018). Patient AA is 15 years old and that means he is an adolescent. He has also not presented with a history of trauma, meaning that his knee injury is atraumatic.
References
Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.
Bunt, C.W., Jonas, C.E., & Chang, J.G. (2018). Knee pain in adults and adolescents: The initial evaluation. American Family Physician, 98(9), 576-585. https://www.aafp.org/afp/2018/1101/p576.html
Gemas, T. (September 28, 2015). Symptoms of kneecap dislocation. Sports-health. https://www.sports-health.com/sports-injuries/knee-injuries/symptoms-kneecap-dislocation
Bilateral Dull Knee Pain Discussion