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S: Subjective
Chief complaint: "My right knee hurts when I walk."
History of present illness: A 66-year-old woman reports gradually worsening right knee pain over 2 years, now 6 out of 10 after walking more than a block or climbing stairs. Pain eases with rest. Morning stiffness lasts about 15 minutes. She hears grinding in the knee. No locking, giving way, recent injury, fever or swelling of other joints. Acetaminophen helps a little.
Past medical history: Hypertension, controlled. No peptic ulcer disease or kidney disease. Medications: Lisinopril 10 mg daily; acetaminophen as needed. Social history: Retired; walks her dog daily but has cut back because of pain. BMI 31.
O: Objective
- Vital signs: blood pressure 128/78, heart rate 74, temperature 36.7 °C.
- Inspection: mild bony enlargement of the right knee; no redness; mild varus alignment.
- Palpation: tenderness along the medial joint line; no warmth; small effusion on the bulge test.
- Range of motion: flexion to 115 degrees with crepitus; full extension.
- Special tests: McMurray test negative; Lachman and anterior and posterior drawer tests show stable ligaments; varus and valgus stress tests stable.
- Gait: mild antalgic gait.
- Other joints: no swelling of hands or other joints.
A: Assessment
Primary diagnosis: osteoarthritis of the right knee. Age over 50, activity-related pain, morning stiffness under 30 minutes, crepitus, bony enlargement and no warmth support a clinical diagnosis without imaging.
Differential diagnoses:
- Meniscal tear: less likely without locking, catching or a positive McMurray test.
- Inflammatory arthritis: unlikely with brief stiffness, a single joint and no warmth or other joint involvement.
- Gout or pseudogout: would usually cause acute, hot swelling.
- Pes anserine bursitis: tenderness would be below the joint line on the medial side.
P: Plan
Based on the 2019 American College of Rheumatology/Arthritis Foundation guideline (Kolasinski et al., 2020):
- Exercise: strongly recommended. Referral to physical therapy for strengthening and low-impact aerobic exercise; tai chi is also strongly recommended.
- Weight loss: strongly recommended for patients with knee osteoarthritis who are overweight or obese. Discuss goals and referral to a nutrition program.
- Self-management: strongly recommended self-efficacy and self-management programs; offer a cane for longer walks if needed.
- Topical NSAID: strongly recommended for knee osteoarthritis. Start diclofenac gel to the right knee up to four times a day, a safer first choice than oral NSAIDs given her age and hypertension.
- If not controlled: an oral NSAID at the lowest effective dose for the shortest time, with blood pressure and kidney monitoring, or an intra-articular glucocorticoid injection (both strongly recommended options).
- Imaging: not needed now; X-ray if symptoms change or before referral for surgery.
- Follow-up: in 8 weeks to review pain, function and blood pressure.
Reference
Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., . . . Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 72(2), 149–162. https://doi.org/10.1002/acr.24131
