Assessing Musculoskeletal Pain
Case 3: Knee Pain
A 15-year-old male reports dull pain in both knees. Sometimes one or both knees click, and the
patient
... [Show More] 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?
Patient Information: Initials: JB Age:15 Sex: Male Race: Hispanic
Subjective:
CC: “ I am having dull pain in both knees with clicking sound for the past two months”
HPI: The patient is a 15-year-old Hispanic male with complains bilateral knee pain associated
with clicking sound and catching sensation under the patella that commenced two months ago
but has progressively worsened over the past two weeks. He denies recent trauma or injury. Also,
he explained that he has had pain during activities that bend the knee, including squatting or
climbing stairs. He describes his discomfort at 10/10 on the pain scale and his symptoms are
sometimes alleviated with resting, applying ice to his knee and taking ibuprofen and Tylenol.
Exacerbating factors include physical activity such as squatting, bending, running as well as
sitting for long hours. He expressed that knee pain has impacted his athletic life significantly
insomnia due to the discomfort that he has experienced.
Current Medications: Tylenol PM 2 Capsules at bedtime for knee pain, ibuprofen 400mg PRN
for pain, Gummy Multivitamin for Teens 12-17 years daily (OTC).
Allergies: Latex- Reaction: Rash & itching, Shellfish- Reaction: Itching and Hives, seasonal
allergies-Reaction- Sneezing and running nose.
Past Medical History: Negative Medical and Surgical History.
Immunization History: Immunization current Influenza vaccine 10/20, Last Tetanus- 02/20
Social History:
JB is a 15-year-old Hispanic teen who resides with him Parents and sister (10 years old)
in a two-story house with modern living convenience. He attends Sierra Middle school where he
is actively involved in track and field, swimming and football. He receives health insurance-Blue
Cross Blue Shield provided through his parents. He stated that he has a good relationship with
his family. His younger sister attends an elementary school, his mother is a Teacher and his Dad
is a Manager at a local bank. He has missed school for a few days because he is unable to
function due to the pain he is experiencing during physical activities. JB denies any smoking,
drinking and or illicit drug use. He denies any dietary restrictions and shares that he eats cereal
for breakfast, hot dogs for lunch and whatever is provided by his parents for dinner. Additionally,
he denies any recent weight gain.
Health Maintenance: 1. Pain management with NSAIDS 2. RICE therap [Show Less]