diagnosis 11

Ms. Roman, a 74-year-old white female with a past medical history of GERD and a remote history of alcohol use disorder, is seen at the clinic for annual checks and with a recent complaint of knee pain. She has no prior trauma or injury history.

Intermittent right knee pain

with mildly decreased ROM

Negative Lachman and McMurray tests

Retired teacher

Crepitus with motion in the right patella

Negative anterior and drawer tests

No pain and normal ROM in all other joints

Small effusion appreciated from milking the right suprapatellar pouch

No pain or laxity with varus or valgus stress

Does not drink or smoke

No history of trauma or surgeries

No fullness in the popliteal fossa

No constitutional symptoms

Less painful in the morning, pain progresses as the day goes on

Favors bearing weight on the left leg

Family history of osteoarthritis

No erythema, edema, bruising, or atrophy

Describes pain as an ache and that knee grinds with movement

Pain is keeping her from her hobby of gardening

Relieves with rest

Lives in a two-story home

Some tenderness to palpation along both the medial and lateral joint lines on the right leg

No skin lesions

Age 74-year-old

No morning stiffness

No fever, numbness, weakness, or tingling

Ms. Roman, a 74-year-old Caucasian female, presented with two weeks of progressively worsening chronic right knee pain. She denies any knee injuries or injury. She characterizes the pain as a dull ache and assigns it a rating of 6/10 on a scale from 0 to 10. She denies experiencing numbness in the morning. She reports that the pain is less severe in the morning and increases during the day. She has solely used Bengay for pain relief. As the pain prevented her from gardening, she opted to have it examined. The physical examination reveals a mildly restricted range of motion in the right knee, along with crepitus and a little effusion, but no erythema or skin abnormalities.

Progressively worsening chronic right knee pain

Favoring left leg with ambulation

Other joint pain

Tenderness on medial and lateral joint lines of right leg

Grinding sensation

Some crepitus and small effusion on right suprapatellar pouch

Pain aggravates with activity and relieves with rest.

Mildly decreased range of motion of the right knee

Family history of osteoarthritis

Negative Lachman and McMurray tests

Female gender

Over 55 years of age

No morning stiffness

Progressively worsening chronic right knee pain

Absence of fever and malaise

Other joint paint

No symmetric polyarthritis

Wrist pain

Mild effusion

Pain aggravates with activity and relieves with rest.

No nodules at pressure joints

Intermittent right knee pain

Tenderness during palpation

Pain aggravates with activity and relieves with rest.

Crepitus with motion

No morning stiffness

Negative Lachman and McMurray tests

Limited ROM of right leg.

History and physical

Osteoarthritis can be diagnosed based on medical history and physical symptoms (Deveza, 2021)

Plain Radiograph

It helps to confirm the diagnosis and rule out other disorders. Joint space narrowing, osteophyte formation, subchondral sclerosis, and cysts are frequently observed in OA. When osteophytes are present, patellofemoral, and tibiofemoral joint osteophytes are the most accurate indicators of disease progression, whereas joint space narrowing is the most accurate predictor of disease progression. (Deveza, 2021).

ESR, CBC and platelets

OA does not cause an increase of ESR, but RA does. To rule out other differential diagnoses, especially when septic arthritis or an acute inflammatory illness is suspected. (Cash et al., 2020).

Rheumatoid Factor Quantitative

The absence of rheumatoid arthritis will be determined by RA quantitative. The test's positive predictive value is 95%, albeit it is not particularly reliable (Maru & Mulla, 2019).

Encourage to do exercise and weight management.

Aerobic and strengthening exercises can have similar positive effects on pain and function as nonsteroidal anti-inflammatory drugs (NSAIDs). In conjunction with exercise, weight control can reduce knee discomfort from osteoarthritis by around 50 percent, especially in people who are overweight or obese (Abramoff & Caldera, 2020).

Recommend the use of a cane and knee braces if necessary.

Canes and knee braces help alleviate pain and should be considered as supplementary treatment (Abramoff & Caldera, 2020).

Pharmacological management

Due to a history of GERD, acetaminophen and topical analgesia should be used initially. Patients can begin taking 325 mg of acetaminophen orally every six hours or as needed, with a daily maximum of 4000 mg.

NSAIDs are the second option, although they are associated with gastrointestinal side effects and cardiovascular risk. To prevent gastritis, omeprazole 20 mg orally at once daily can be taken in conjunction with NSAIDs. Patients might begin treatment with capsaicin cream and apply it three to four times daily (Deveza, 2021).

If the patient's symptoms persist, intra-articular injections may be indicated. Before injection, 1% lidocaine solution is combined with the steroid (Deveza, 2021). Rest and minimize joint activity for 48 to 72 hours following injection (Deveza, 2021).

Oral glucocorticoids for moderate to severe rheumatoid arthritis. To avoid joint damage, the first-line treatment for RA includes disease-modifying antirheumatic medicines (DMARDs). Inform the patient of the risks, benefits, adverse effects, and warnings associated with these medications. It is also crucial that patients receive routine laboratory monitoring while taking these drugs (American College of Rheumatology, 2021).

Discuss immunizations, particularly for influenza and pneumonia

DMARDs impair the immune system and increase infection risk (Cash et al., 2020).

Physical and Occupational Therapy

If indicated, it should be initiated. Physical therapy strengthens muscles, enhances motion range, and diminishes pain (Deveza, 2021).

Surgical management

Referral to a knee replacement surgeon is needed if all other options fail. (Cash et al., 2020).

Follow-up after 2 to 4 weeks

Ms. Roman should return to the clinic for a wellness examination and evaluation of pain treatment.