Musculoskeletal Case Episodic/Focused SOAP Note

 

Patient Information:

M.M., 15 years old, Male, Caucasion

S.

CC (chief complaint) “knee pain with a clicking sound under the knee cap, and sometimes it catches”

HPI: Patient just turned 15 and began playing for varsity basketball. Since starting varsity practice, 1 weeks ago, he’s noticed mild swelling and pain under the knee cap. Pain is worse when running and jumping.

Location: bilateral knees

Onset: 6 days ago

Character: catching knee pain

Associated signs and symptoms: minimal swelling of bilateral knee under patella, right greater than left

Timing: pain constant but minimal, however, increases with activity

Exacerbating/ relieving factors: activity increases pain; rest, ice, and elevation decrease pain

Severity: 4/10 pain scale

Current Medications: ibuprofen 200mg Q6 hours PRN for pain

Allergies: allergy to shellfish – causes generalize hives

PMHx: Tonsillectomy at age 7, All UTD, last TDAP 2019

Soc Hx: Patient denies alcohol, tobacco/nicotine, and illicit drugs

Fam Hx:

Mother: asthma, IBD

Father: depression

Sister: bilateral hallux valgus deformity

Maternal grandmother and grandfather: unkown history due to closed adoption of mother

Paternal grandfather: died of testicular cancer age 38

Paternal grandmother: hypertension and diabetes type II

ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Wears contact lenses, denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies dysuria, denies increased frequency, denies discharge.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, or stiffness. Patient states new bilateral knee pain.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, eczema or rhinitis. States allergic to shellfish with generalized hives

O.

Physical exam:

Vital signs: B/P 114/78, left arm, sitting, regular cuff; P 52 and regular; T 97.9 Orally; RR 18; non-labored; Wt: 141 lbs; Ht: 5’11; BMI 19.7

General–Pt appears calm and cooperative, athletic build, does not appear ill

Cardiovascular—RRR without murmur, negative rub/gallup

Respiratory— Lungs clear in all fields, no adventitious sounds, no increased work of breathing

Musculoskeletal – symmetric muscle development – muscle strength appropriate 5/5 in all groups, DTR’s intact, trace swelling left knee, +1 edema right knee, redness bilaterally. Increased pain with palpation over tibial tuberosity. Slight prominence at tibial tubercle. Full ROM on passive, Poor flexibility of hamstring on active ROM right less than left.

Basset sign/Passive flexion-extension sign: negative

Standing active quadriceps sign: negative

Lachman test: negative

McMurray test: negative

Apley grind test: negative

 

Diagnostic results:

X-ray bilateral knee: negative for fracture, infection, and tumor; negative for avulsion; positive for soft tissue swelling

Ultrasound: negative for negative for edema and microtrauma on patellar tendon, positive for soft tissue edema and positive for minimal bony formation proximal tibia

MRI: postponed if pain does not subside

A.

Osgood-Schlatter Disease

Patient with Osgood-Schlatter Disease, also known as osteochondrosis, have inflammation of the anterior part of the tibia that is growing (Ball, Dains, & Flynn, 2019). Patients experiencing pain are using undergoing a growth spurt and pain come with increased activity such as running and jumping; pain is more significant in immature athletes (Smith & Varacello, 2022). Typically, adolescents, ages nine to fifteen are affected but outgrow this disease once they are no longer having large growth-spurts. Upon examination, there is inflammation of the anterior patellar tendon (Ball, Dains, & Flynn, 2019). Diagnosis is made clinically, however, radiographs may show slight prominence and soft tissue swelling, otherwise negative for pathology. Fortunately, the pain usually improves with rest and responds to NSAIDs, however, pain can reoccur for approximately two years during rapid bone growth and development (Smith & Varacello, 2022).

Patellar tendonitis

Patellar tendonitis is also called “jumper’s knee” which is a painful condition where small tears on the patellar tendon occur with high impact sports. Patellar tendonitis is an injury of overuse and in the early stages, can cause microtears and lesions on ultrasound. If left untreated, the patient can show lesions and a thick envelope appearance on the patellar tendon. Patellar tendonitis will have positive basset’s sign and positive standing active quadriceps sign where there is tenderness in a fully extended knee and in a bent knee along the proximal part of the patellar tendon or while the quadricepts are activated (Rath, Schwarzkopf, & Richmond, 2010).

Meniscal Injury

Meniscal tears are suspected on a complete history and physical and with a proper interview where the patient will describe the knee pain with catching, buckling, popping, or locking. There can be synovitis and ACL tears associated with meniscal tears or degeneration, if an ACL tear is present, the patient may have a positive Lachman’s test. A meniscal tear is diagnosed, or suspected, with a positive McMurray test where a click occurs and a patient complains of pain with external rotation of the leg while supine, a positive Apley test where the patient is prone and pain is felt when the tibia is compressed and the leg is externally rotated, or with a positive bounce home test where the knee is passively brought up and pain is felt when allowed to extend. Although, clinically diagnosable, an MRI is typically ordered for suspected meniscal and ACL tears (Maffulli, Longo, Campi, & Denaro, 2010).

Infrapatellar Bursitis

With infrapatellelar bursitis, the pain is near the attachment of the patellar tendon, however, on physical exam, the pain is not increased with palpation of the tibial tuberosity. An MRI is needed to diagnose infrapatellar bursitis to show fluid collection in that region with no abnormalities of the tibial tuberosity (Vaishya, Azizi, Agarwal, & Vijay, 2016). The inflammation occur in the bursa, typically in large joints after trauma which increases blood flow and an inflammatory response. Bursitis can be acute or chronic and can occur across the lifespan. A needle aspiration may be required if pain does not decrease to determine if any infection or crystalline feature are noted to change the differential diagnosis (Rishor-Olney & Pozun, 2022).

Osteomyelitis

Osteomyelitis of the knee is relatively rare but can be a serious complication of an infection, particularly after an intra-articular injection. Although rare, delayed treatment can have serious affects and may lead the patient to a poor prognosis. Fortunately, osteomyelitis can be seen on imaging such as an MRI. A needle aspiration of the knee can also show infection of the joint space, however, blood cultures will likely be negative unless the infection has progressed. On clinical exam, the patient will have a painful swollen knee and a limp, usually unilaterally. It’s cause is not related to physical activity, however, activity can increase the pain (Devnani, Kiat Yeak, & Fahrudin, 2020).

References

Ball, J. W., Dains, J. E., & Flynn, J. A. (2019). Seidel’s Guide to Physical Examination. St. Louis: Elsevier Health Sciences.

Devnani, A. S., Kiat Yeak, R. D., & Fahrudin, C. H. (2020, March 31). Osteomyelitis of the Knee Following Intra-Articular Injections: A Case Series. Retrieved from Journal of Nepal Medical Association: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580306/

Maffulli, N., Longo, U. G., Campi, S., & Denaro, V. (2010, April 26). Meniscal Tears. Retrieved from Open Access Journal of Sports Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3781854/

Rath, E., Schwarzkopf, R., & Richmond, J. C. (2010, October-December). Clinical Signs and Anatomical Correlation of Patellar Tendinitis. Retrieved from Indian Journal of Orthopaedics: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947732/

Rishor-Olney, C. R., & Pozun, A. (2022, September 6). Prepatellar Bursitis. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK557508/

Smith, J. M., & Varacello, M. (2022, September 4). Osgood Schlatter Disease. Retrieved from StatPearls: https://www.ncbi.nlm.nih.gov/books/NBK441995/

Vaishya, R., Azizi, A. T., Agarwal, A. K., & Vijay, V. (2016, September 13). Apophysitis of the Tibial Tuberosity . Retrieved from Cureus: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063719/