Chief Complaint: Knee Pain
History of Present Illness
A 59 y.o. male in town for a conference comes to the urgent clinic with severe right knee pain. His knee was fine yesterday when he played nine holes of golf. He describes a history of osteoarthritis in both knees for which he takes celecoxib. Also, about a month earlier, he got an injection in his right knee that resulted in decreased pain and asks if another knee injection would help. This pain is now much worse than last month; this time his knee is very red and swollen. He does not recall an injury and has never experienced a similar pain in any joint.
Past Medical History/Current Meds
• Diabetes treated with metformin and sitagliptin ER combined
• Hypertension treated with HCTZ and irbesartan
• Hypothyroidism treated with levothyroxine
Eats three meals daily, most of which are eaten out, and eats “more sweets than I should.” Habits include approximately one-half a pack of cigarettes per day and two to three beers daily. Tries to walk 20 minutes every day to help keep his weight down but comments “I sure won’t be walking with this.”
Review of Symptoms
As noted per HPI only, not completed
• Vital signs: HR 98, BP 150/92, HT 70, WT 195 lbs.
• General: Slightly obese, appropriately dressed, obvious limp, with facial expression indicating pain on movement.
• CV: S1/S2, RR&R. No murmur.
• Respiratory: Decreased breath sounds bilaterally, scattered crackles that clear with cough.
• Upper extremities: FROM, strength 2+, coordinated. No lesions, deformities.
• Lower extremities: Right knee is erythematous and warm, approximately 30% larger than left. Unable to fully assess for effusion, nodules, and so on due to pain. Tender to light touch, pain with any movement. Left leg ROM without pain, knee ROM with slight crepitus. 1+ ankle/foot edema bilaterally.
Case Study Discussion – Part I:
Answer the following and post your response in the Case Study Part I by creating your own initial thread.
Identify a minimum of three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What further history, further examination, and diagnostic studies should be considered in order to explore your differential diagnosis and confirm your suspicions?