Diagnosis and Assessment: Patient Presenting Knee Pain

Diagnosis and Assessment want-suffering Presenting Knee PainStephen ChiangPresenting ComplaintMr X is a 72 twelvemonth old man who presented to the GP clinic with worsening right knee distressingness for the past 3 weeks. register of Presenting ComplaintPain has worsened everywhere the past 3 weeks.Pain is around the patella with no radiation therapy of discommode.Described as a constant dull waste that worsens at the end of the day after activities.Not relieved by both pain in the ass medication. Previous trial on NSAIDs and panadolosteo.Pain and grounds does non improve during the day. Denies some(prenominal) morning stiffness.Complains of knee being swollen and close the range of movement.Denies any locking or catching of the knees.Pain has certified his movement causing him to lose balance.No history of falls.Denies any late injury or trauma to the knee.Past Medical History abdominal aortic aneurysm2014Pulmonary Fibrosis2014COPD infective exacerbation2012GORDMedic ationsMetoprolol 50mgPanadol Osteo SR665mgVytorin10mg/20mgRabeprazole10mgPrednisolone25mgAllergies/ Adverse ReactionsPenicillins flake rashImmunisation-VAXIGRIP providedFamily History nil knownSocial HistoryLives alone in Collie. No support services required.Non-smoker. 1 normal drink several times a week.Limited physical activitiesNo history of substance abuseExaminationPleasant looking ripened man.Not in any obvious distress. Alert and oriented to time, station and person. Good mobilityVitals BP 155/88 mmHg, HR 78bpm and regular, RR 17, afebrilecardiovascular Heart sound dual, nil added. JVP non elevated, all peripheral pulses atomic number 18 palpableRespiratory symmetrical rise and fall of chest with respiration, bibasal crepitations heard, no wheeze. Not in respiratory distressAbdomen no scars noted, venter soft, non supply ship, bowel sound presentKnee no deformities, swelling or muscle wasting noted. No obvious signs of effusion. Bulge test and patellar tap nega tive. No erythema and not warm. Crepitations heard with movement of knee. Not tender on palpation.Full range of movement with active and passive movement with pain. (extension, flexion, rotation). Ligament stability test NADInvestigations Ordered Bilateral Knee roentgen rayMurtaghs Diagnostic ModelFactors in initial history / mental test supporting diagnosisFactors in initial history / examination non supporting diagnosisFactors in subsequent history / examination / investigating influencing diagnosisPROBABLE diagnosisOsteoarthritis Swelling of the kneeAge, chronic Pain, Asymmetrical, Weight bearing joint, Worse with movement, Crepitus on movementLigament strains No introductory injuries or traumaAsymmetrical knee painSerious disorders not to missNeoplasia primary in bone metastases No night sweats, no weight hurt, no indication of previous X-ray constant ache day and nightSevere infections septic arthritis No fever, no redness, inspiration or swelling of joint. No hx of tr aumaVascular disorders deep venous thrombosis superficial thrombophlebitis No long periods of immobilisation No previous hx of clots goose egg tenderness around muscle unilateral painPitfallsGout/ pseudogout No previous hx of goutReferred pain back or hip Denies any pain of the back and hipMasqueradesDiabetes No polyuria, polydipsia, Normal Fasting BSL spinal anesthesia dysfunctionAnother agenda?DepressionLives on his own, poor ancillary relationship,Management Plan (Whole person)1. Knee pain RICE therapy, Weight loss knee X-ray Adequate pain guidance Referral to orthopaedic surgeons for brush up Referral to physiotherapist strengthen quadriceps2. Pulmonary Fibrosis/ COPD Prevent infective exacerbations hold open follow up with respiratory physicians in Perth Yearly influenza inoculation/ 5 yearly pneumovax Referral to chest physiotherapist3. Abdominal aortal Aneurysm Yearly monitoring of AAA Continue follow up with vascular surgeon in PerthPreventative Health Activities1. Nu trition uncomplaining education on maintaining healthy diet. Referral to dietician2. Weight review 6 monthly to ensure BMI 23. Physical activity education on appropriate exercise routine. Referral to physiotherapist4. Alcohol intake reduction of alcoholic beverage intake5. General monitor BP 6 monthly, yearly monitoring of FBC UEC lipoid profile6. Cancer screening colorectal every 2 old age7. Vision, hearing and fall risk assessmentUnable to follow up with patient as patient returned to GP in Collie while I was based in Bunbury. No access to patients provide from Bunbury.Clinical Evidence BaseIn patients with degenerative arthritis of the knee (OAK), is intra-articular sex hormone injection more effective compared to other pharmacological handling such(prenominal)(prenominal) as NSAIDs and glucosamine in legal injury of skill and managing pain?Osteoarthritis is the near common joint disease affecting adults older than 65 age old. In Australia alone, osteoarthritis a ffects more than 1.3million adults.1 Osteoarthritis can significantly match the quality of life because of the restriction in mobility ca employ by the pain. In osteoarthritis of the knee (OAK), the main form of word remains partial or total knee replacement.4 However, there are still a colossal number of patients who are unable to undergo such intervention. In such patients, interpositions are limited to safer alternatives such as NSAIDs, opioids, glucosamine supplements and intra-articular steroid injection.The OneSearch UWA library database was searched and keywords used were osteoarthritis, knee, pharmacological, NSAIDs, steroid. Other related margins were included in the search. One study was identified, in brief term efficacy of pharmacotherapeutic interventions in osteoarthritis knee pain by Jan Magnus Bjordal, Atle Klovning, Anne Elisabeth Ljunggren and Lars Slordal.2The study is a meta-analysis of randomised placebo controlled trials with a sample study size of 14,060 patients in 63 trials measuring pain intensity within 4 weeks of treatment and at 8-12 weeks follow up using the visual analogue scale (watercraft).2Results indoors 4 weeks viva voce NSAIDs, pain relief measured 10.2mm on the VAS (95% CI8.8-11.6). Steroid injection arrayed 14.5mm (95% CI9.7-19.2), paracetamol 3.0mm (95% CI1.4-4.7), glucosamine 4.7mm (95% CI 0.3-9.1), chondroitin sulphate 3.7mm (95% CI0.3-7.0).28-12 weeks follow up oral NSAIDs and steroid injection showed decline in efficacy 9.8mm. Paracetamol did not show change in efficacy. Glucosamine showed 3.8mm efficacy and chondroitin sulphate showed an increase in efficacy of 10.6mm.2Strength and Weaknesses of this study1. Level 1 evidence based on NHMRC2. Outcome and methods of measure was clearly explained and defined.3. Inclusion and exclusion criteria were clear.1. Measuring of pain intensity with the visual analogue scale (VAS) is very subjective.2. Bias in terms of NSAIDs users selection in certain trials.3. Compar ing various treatment options by assessing separate meta-analyses for each treatment may have different baseline data and prognostic factors.4. All steroid injection trials were performed in a fixed setting limiting their application into primary flush context. Duration of trial of 4 weeks may be too short to analyse efficacy of some treatments.Findings showed that there is better short term pain relieve when using steroid injection compared to the other treatment options. However, steroid and oral NSAIDs have the same efficacy in long term. Chondroitin sulphate also showed a negligible pain relieve in the long term.Application This study was done in Norway and it showed that there is minimal pain relieve by using current treatment options such as steroid injections, oral NSAIDs and supplements. Further studies should be performed to compare patients in Australia. Patients should be educated about the efficacy of such pharmacological treatment to lower their expectations. We sho uld start reconsidering the role of these treatments in future pain management of osteoarthritis. This patient was started on many treatments that did not offer any pain relieve that corresponds to the results of the study stated above. Hence, he was referred to an orthopaedic surgeon for foster review and management plan.References1. Australian Institute of Health and Welfare. A prototype of Osteoarthritis.Department of Health and AgeingOctober 2007 Arthritis Series Number 52. Jan Magnus Bjordal a,*, Atle Klovning a , Anne Elisabeth Ljunggren a , Lars Slrdal b. short-run efficacy of pharmacotherapeutic interventions in osteoarthritic knee pain A meta-analysis of randomised placebo-controlled trials.European daybook of Pain8 May 2006 11, 125-1383. Carlos J Lozada, MD Director of Rheumatology Fellowship Training Program, prof of Clinical Medicine, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine.Osteoarthrit is. http//emedicine.medscape.com/ oblige/330487-overview (accessed 17/06/2015)4. S.P. Krishnana, , J.A. Skinnerb. Novel treatments for early osteoarthritis of the knee.Current OrthopaedicsDecember 2005 Volume 19(Issue 6), Pages 407-414