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Patient Initials: RF               Age: 15                       Gender: M

SUBJECTIVE DATA:

Chief Complaint (CC): A dull pain in both knees with occasional clicking in one or both knees and the sensation of the patella catching.

History of Present Illness (HPI): RF is a 15-year-old male who reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. He states that the pain has been on and off for the last four months and initially only present after intense activity but has gotten worse since starting track this summer and seems to be present more often than before.

The patient states that the clicking comes and goes and isn’t always present in both knees at the same time. The catching sensation under the patella is more pronounced since he started doing the long jump in track. The patient states that he is able to bear weight as the pain is a dull ache. Icing his knees after sports and taking ibuprofen help to reduce the pain and swelling but both occur more frequently now making it difficult to participate in sports. The patient feels that he may be overdoing it with all of the sports he participates in and is worried about not being able to play soccer if it continues to get worse. The patient rates the pain 7/10 after intense activity.

Medications: Ibuprofen 200 mg oral tab, two tabs every 6 hours as needed for pain.

 Allergies: No known drug, food, or environmental allergies.

Past Medical History (PMH): None

Past Surgical History (PSH): None 

Sexual/Reproductive History: Patient is not sexually active at this time.

Personal/Social History: Patient denies smoking, alcohol use, and illicit drug use. The patient is very active with sports playing soccer, basketball, baseball, and track. He states that he tries to eat well mainly because of sports but doesn’t always make the best choices for snacks. He tries to avoid soda most of the time and reports drinking a lot of water.

Immunization History: Immunizations are up to date. Gets influenza vaccine annually.

Significant Family History:

Paternal grandfather has hypertension, and father has borderline hypertension. Maternal grandfather has type II diabetes.

Lifestyle: RF is a freshman in high school who lives with both of his parents and older sister. RF plays soccer, basketball, baseball and participates in track for high school. RF also plays club soccer playing and traveling most of the year. RF is a good student, athletic, and enjoys being active. He also participates in winter sports and skis during winter break.  RF works part-time as a referee during the summers due to his commitment to school and sports.

Review of Systems:

General: No recent weight gain or loss of significance. Patient denies fatigue, fever, or chills.

HEENT: No headaches or dizziness. No changes in vision. He does not wear glasses, and his last eye exam was just under a year ago. Denies eye drainage, pain, or double vision. No changes in hearing. Has had no recent ear infections, tinnitus or ringing in the ears. Denies sinus infections, congestion, and epistaxis. He reports his sense of small is intact. Last dental exam was four months ago for regular cleaning. Denies bleeding gums or a toothache. Denies dysphagia or throat pain.

Neck: No history of trauma, denies recent injury or pain. He denies neck stiffness.

Breasts: Denies any breast changes. Denies history rashes. Denies history of masses or pain.

Respiratory: Denies a cough, hemoptysis, and sputum production. Patient denies any shortness of breath with resting or with exertion. Patient reports no pain with inspiration or expiration.

Cardiovascular/Peripheral Vascular: No history of murmur or chest palpitations. No edema or claudication. Denies chest pain. No history of arrhythmias.  

Gastrointestinal: Denies nausea or vomiting. Patient reports no abdominal pain, diarrhea, or constipation. Last bowel movement was this morning. Denies rectal pain or bleeding. Denies changes in bowel habits. Denies history of dyspepsia.

Genitourinary: Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, the patient is heterosexual and not sexually active. Denies hematuria. Denies urgency, frequency, and dysuria.

Musculoskeletal: No limitation in range of motion for all limbs though patient reports difficulty moving knees after excessive strain from sports.  No history of trauma or fractures. Patient reports dull pain in both knees. The patient states occasional swelling in knee joints after participating in sports. Patient reports clicking in one knee and sometimes both. The patient states that the pain is worse after participating in the long jump or running long distances. Patient denies history or presence of misalignment of either knee.

Psychiatric: Denies suicidal or homicidal history. No mental health history. Denies anxiety and depression.

Neurological: No dizziness. No problems with coordination. Denies falls or seizures. Denies numbness or tingling. Denies changes in memory or thinking patterns.

Skin: No history of skin cancer. Denies any new rashes or sores. Patient reports many blisters from sports which are treated with Neosporin, band-aids, and NewSkin spray. Denies eczema and psoriasis. Denies itching or swelling.  

Hematologic: No bleeding disorders or history of blood transfusion. Denies excessive bruising.

Endocrine: Patient reports no endocrine symptoms. Denies polyuria, polydipsia. Patient denies no intolerance to heat or cold.

Allergic/Immunologic: Denies environmental, food, or drug allergies. No known immune deficiencies.

OBJECTIVE DATA:

 Physical Exam:

Vital signs: B/P 118/74; P 65 and regular; T 98.6; RR 16; O2 100% on room air; Wt: 125 lbs.; Ht: 5’7”; BMI 19.1

General: RF is a well-developed, well-nourished Caucasian teenage male who appears to be in no apparent distress.   

HEENT: Head: Skull is normocephalic, atraumatic. No masses or lesions.

Eyes: PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. Fundoscopic exam normal, vessels intact, the optic disc with clear margins.

Ears: Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally.

Nose: No nasal flaring, no discharge, no obstruction, septum not deviated. Turbinates pink and moist. No polyps or lesions bilaterally. Nares patent with no edema or erythema.

Throat: Oropharynx clear and mucosa moist. No erythema or exudate. Uvula midline, palate rises symmetrically.

Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline.

Neck: Supple, non-tender. Full range of motion. Trachea midline. No masses. Thyroid and lymph nodes not palpable.

Chest/Lungs: Thorax non-tender with symmetric expansion. Respiration regular and unlabored, without a cough. Tactile fremitus equal bilaterally and greater in upper lung fields.  Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones.   

Heart: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. Apical pulse was barely palpable. JVP appears to be approximately less than 6 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated.

Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally.

Abdomen: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds. Tympany over most quadrants with areas of dullness noted upon percussion. No abdominal bruits.

Genital/Rectal: Adequate tone, no masses noted, eternal genitalia intact.

Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal joint inflammation or abnormalities appreciated in upper extremities. + tenderness to palpation at the inferior pole of the patella bilaterally. + Q angle greater than 10 degrees bilaterally. Clicking present with movement in right knee. Normal alignment of the knees bilaterally. All upper and lower extremity joints without effusions or erythema. Spine without tenderness and range of motion is full. Greater tenderness was noted in knees bilaterally when extended, and quadriceps are relaxed. Normal muscle strength present against resistance.

Neurological: CN ll-Xll grossly intact. Awake, alert, and oriented to person, place and time. The patient can move all limbs on command and spontaneously.

Skin: Warm, moist, and intact. Skin is pale. + edema right knee. No peripheral cyanosis. No clubbing. No rashes or bruises present.

ASSESSMENT:

Lab Tests and Results:

CBC- Normal

Erythrocyte sedimentation rate (ESR) – Normal

Diagnostic test:

Passive extension-flexion sign- positive- which is tenderness on palpation of the tendon at the inferior pole of the patella.

McMurray test- Negative for locking during joint movement.

X-ray- negative

MRI- Showed high signal intensity within the proximal posterior central aspect of the tendon at its origin.

Differential Diagnosis:

  1. Patellar tendinitis: This is the most likely diagnosis based on the patients HPI, ROS, physical assessment, and diagnostic studies. The patient’s chief complaint was a dull pain in the knees with occasional clicking in one or both knees. The patient is athletic and participates in many sports that continuously put a strain on his knees. The quadriceps angle was greater than ten which suggests patellar tendinitis. The patient plays sports that include a lot of running and jumping which adds strain to the knee joints. The patient was also positive for tenderness on palpation at the inferior pole of the patella bilaterally. Lastly, the MRI was positive for high signal intensity within the proximal posterior central aspect of the tendon where it originates from.
  2. Osgood Schlatter’s disease: A possible diagnosis as it is a common problem which typically occurs during times of fast growth usually in fit, active boys. Osgood Schlatter’s disease is associated with pain just below the kneecap in one or both knees, often worse after sports especially high impact activities using the quadriceps muscles. However, limping is often a present, and the patient denied limping in the ROS. Pain is greater with stair climbing and kneeling, and the patient did not admit to either. Flexion and extension will increase pain in the tibial tubercle which was not present upon physical exam of the patient.
  3. Chondromalacia patellae: This is a possible diagnosis due to the presence of knee pain upon palpitation and increased pain with activity. However, chondromalacia patellae are more common in females or persons with a history of knee trauma. The patient is male and denied trauma to either knee. The patient denied a history of misalignment which is also related to chondromalacia patellae. An x-ray of the knee would show irregularities of the patellofemoral joint.
  4. Medial meniscus tear: This diagnosis is a possibility because it can occur after a twisting injury and the patient participates in sports such as soccer, basketball, and skiing that involve twisting movements. Clicking may be present with a medial meniscus tear which the patient reported and was also appreciated upon physical assessment in the right knee. McMurray test was negative for locking during joint movement. The patient denied difficulty with weight bearing.
  5. Juvenile rheumatoid arthritis (JRA): Possible due to knee joint soreness and stiffness, however, both typically improve with activity. Joint swelling may also present with JRA and was reported by the patient in his ROS. The patient denied weight loss and fatigue which are common symptoms. The patient also denied night pain. A CBC would show anemia, leukocytosis, and thrombocytosis. The ESR would be elevated.

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Huether, S. E., & McCance, K. L. (2017). Disorder of the joints. In alterations of musculoskeletal function (6th ed., pp. 991-1038).

Rath, E., Schwarzkopf, R., & Richmond, J. (2010). Clinical signs and anatomical correlation of

patellar tendinitis. Indian Journal of Orthopaedics44(4), 435-437 3p. doi:10.4103/0019-

5413.6931

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