Physical Exam

Vital signs: B/P 118/74; P 65 and regular; T 98.6; RR 16; O2 100% on room air; Wt: 125 lbs.; Ht: 5’7”; BMI 19.1

General: RF is a well-developed, well-nourished Caucasian teenage male who appears to be in no apparent distress.

HEENT: Head: Skull is normocephalic, atraumatic. No masses or lesions.

Eyes: PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. Fundoscopic exam normal, vessels intact, the optic disc with clear margins.

Ears: Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally.

Nose: No nasal flaring, no discharge, no obstruction, septum not deviated. Turbinates pink and moist. No polyps or lesions bilaterally. Nares patent with no edema or erythema.

Throat: Oropharynx clear and mucosa moist. No erythema or exudate. Uvula midline, palate rises symmetrically.

Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline.

Neck: Supple, non-tender. Full range of motion. Trachea midline. No masses. Thyroid and lymph nodes not palpable.

Chest/Lungs: Thorax non-tender with symmetric expansion. Respiration regular and unlabored, without a cough. Tactile fremitus equal bilaterally and greater in upper lung fields.  Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones.

Heart: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. Apical pulse was barely palpable. JVP appears to be approximately less than 6 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated.

Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally.

Abdomen: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds. Tympany over most quadrants with areas of dullness noted upon percussion. No abdominal bruits.

Genital/Rectal: Adequate tone, no masses noted, eternal genitalia intact.

Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal joint inflammation or abnormalities appreciated in upper extremities. + tenderness to palpation at the inferior pole of the patella bilaterally. + Q angle greater than 10 degrees bilaterally. Clicking present with movement in right knee. Normal alignment of the knees bilaterally. All upper and lower extremity joints without effusions or erythema. Spine without tenderness and range of motion is full. Greater tenderness was noted in knees bilaterally when extended, and quadriceps are relaxed. Normal muscle strength present against resistance.

Neurological: CN ll-Xll grossly intact. Awake, alert, and oriented to person, place and time. The patient can move all limbs on command and spontaneously.

Skin: Warm, moist, and intact. Skin is pale. + edema right knee. No peripheral cyanosis. No clubbing. No rashes or bruises present.

ASSESSMENT:

Lab Tests and Results:

CBC- Normal

Erythrocyte sedimentation rate (ESR) – Normal

Diagnostic test:

Passive extension-flexion sign- positive- which is tenderness on palpation of the tendon at the inferior pole of the patella.

McMurray test- Negative for locking during joint movement.

X-ray- negative

MRI- Showed high signal intensity within the proximal posterior central aspect of the tendon at its origin.

Differential Diagnosis:

1. Patellar tendinitis: This is the most likely diagnosis based on the patients HPI, ROS, physical assessment, and diagnostic studies. The patient’s chief complaint was a dull pain in the knees with occasional clicking in one or both knees. The patient is athletic and participates in many sports that continuously put a strain on his knees. The quadriceps angle was greater than ten which suggests patellar tendinitis. The patient plays sports that include a lot of running and jumping which adds strain to the knee joints. The patient was also positive for tenderness on palpation at the inferior pole of the patella bilaterally. Lastly, the MRI was positive for high signal intensity within the proximal posterior central aspect of the tendon where it originates from.
2. Osgood Schlatter’s disease: A possible diagnosis as it is a common problem which typically occurs during times of fast growth usually in fit, active boys. Osgood Schlatter’s disease is associated with pain just below the kneecap in one or both knees, often worse after sports especially high impact activities using the quadriceps muscles. However, limping is often a present, and the patient denied limping in the ROS. Pain is greater with stair climbing and kneeling, and the patient did not admit to either. Flexion and extension will increase pain in the tibial tubercle which was not present upon physical exam of the patient.
3. Chondromalacia patellae: This is a possible diagnosis due to the presence of knee pain upon palpitation and increased pain with activity. However, chondromalacia patellae are more common in females or persons with a history of knee trauma. The patient is male and denied trauma to either knee. The patient denied a history of misalignment which is also related to chondromalacia patellae. An x-ray of the knee would show irregularities of the patellofemoral joint.
4. Medial meniscus tear: This diagnosis is a possibility because it can occur after a twisting injury and the patient participates in sports such as soccer, basketball, and skiing that involve twisting movements. Clicking may be present with a medial meniscus tear which the patient reported and was also appreciated upon physical assessment in the right knee. McMurray test was negative for locking during joint movement. The patient denied difficulty with weight bearing.
5. Juvenile rheumatoid arthritis (JRA): Possible due to knee joint soreness and stiffness, however, both typically improve with activity. Joint swelling may also present with JRA and was reported by the patient in his ROS. The patient denied weight loss and fatigue which are common symptoms. The patient also denied night pain. A CBC would show anemia, leukocytosis, and thrombocytosis. The ESR would be elevated.

Physical Exam

Physical Exam

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Huether, S. E., & McCance, K. L. (2017). Disorder of the joints. In alterations of musculoskeletal function (6th ed., pp. 991-1038).

Rath, E., Schwarzkopf, R., & Richmond, J. (2010). Clinical signs and anatomical correlation of

patellar tendinitis. Indian Journal of Orthopaedics, 44(4), 435-437 3p. doi:10.4103/0019-

5413.6931