MABEL JOHNSON iHuman Case Study ’76 year old’ “Knee Pain”

Anam Maredia

NURS 6152 B

Section 200

Mabel Johnson

A. History (Subjective) (S)

1. Identifying data (ID): Mabel Johnson, a 76-year-old African

American female that resides in an apartment on the second floor.

2. Chief complaint (CC): “I am having pain in my knees and I am

ready to do something about it. That is why they sent me to you.

My knees have been getting worse over the past couple of years.

They hurt when I walk for more than a block and when I climb

stairs. “

3. History of present illness (HPI)

a. Analysis of symptom/complaint:

Ms. Mable Johnson complains of pain in her knees that stared

about five years ago but has gotten worse over time. The location

of her pain is inside her knees, and the pain in her right knee is

worse. The pain in her right knee radiates down to her ankle. Ms.

Johnson describes the pain in her knees as stiff and achy. They

are stiff in the morning for about 15-20 minutes. Cold weather and

exercise makes her knee pain worse. She hasn’t found anything

that helps with the pain. Ms. Johnson states that her pain level is

usually about a 4 or 5 out of 10, and sometimes it is a 7 or 8 out of

10. Associated symptoms with the pain are swelling in her knees

and sometimes her finger knuckles.

b. Impact on lifestyle

Ms. Johnson has trouble getting around due the pain in her knees.

Ms. Johnson states, “I have to walk up the stairs to get to it. Thank

goodness I don’t live on the 3rd floor. It’s getting harder and harder

to get up those stairs. My daughter usually has to come help me.”

c. Include significant chronic health disorders that impact on the

current chief complaint.

Ms. Johnson has a past medical history of peptic ulcer disease with

GI bleed from Ibuprofen use, chronic kidney disease, and

hypertension.

4. Allergies: Ms. Johnson denies allergies to medication, food,

pollens and pet dander (environmental).

5. Immunizations: Up to date

6. Past medical history (PMH) –

a. Past medical disorders/illnesses

Hypertension (for the last 20 years)

Chronic Kidney Disease

Peptic Ulcer Disease with GI bleed from Ibuprofen 4 years ago.

b. Past surgical history (PSH)

No past surgical history

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c. Injuries/disabilities

Patient reports no injuries or disabilities.

d. Other hospitalizations

Denies hospitalization.

e. Childhood illnesses

Patient does not report any childhood illnesses.

f. Recent health exams

Last physical was completed 9 months and 19 days ago.

g. Preventive health care

Ms. Mable refuses to get mammograms after she had one at age

60. Pap smear in the past have been negative. Last pap smear

was done more than 5 years ago. Colonoscopy was done 4 year

go, 2 hyperplastic polyps were removed.

h. OB/GYN: G6 P6, all children are living.

7. Medications:

Amlodipine 10 mg tab, 1 tab PO daily

Lisinopril 10 mg tab, 1 tab PO daily

Simvastatin 20 mg tab, 1 tab PO daily

Hydrochlorothiazide 25 mg tab, 1 tab PO daily

Protonix 40 mg tab, 1 tab PO daily

Acetaminophen prn headaches or pain

Multivitamin daily

8. Family history: (FH)

Mother- arthritis and obesity

Father-unknown

Sister- HTN

9. Behavioral History:

Denies tobacco, alcohol, recreational drugs use. Also, denies

participating in any sexual practices.

10. Social History:

Lives alone in an apartment that is on the second floor. Due to her

knee pain, Ms. Johnson has trouble getting around. Her daughter

helps her out.

11. Diet/Nutrition:

Diet and nutrition has been adequate.

B. Review of systems (ROS) – Do a complete ROS of all systems. Always on

every patient – episodic & complete physical exam.

General:

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Patient denies any recent weight changes, fever, or fatigue. Patient states,

“because of my pain I am moving around less and I think that is making me

weaker.

Skin:

Patient denies any itchy scalp, skin changes, moles, thinning hair. Patient states,

“as I age my nails seem less strong.”

Head, Neck, Ears, Nose, Throat (HEENT):

Head:

Patient denies any headache, head injury, dizziness or lightheadedness.

Eyes:

Patient denies pain, redness, excessive tearing, double or blurred vision, sports,

specks, flashing lights, glaucoma, and cataracts.

Ears:

Hearing good. Denies tinnitus, vertigo, earaches, infection, or discharge.

Neck:

Denies lumps, goiter, pain. Reports no swollen glands.

Throat:

Reports no bleeding gums, sore tongue, dry mouth, frequent sore throats, and

hoarseness

Breast:

Patient denies lumps, goiter, pain, or discharge.

Respiratory:

Patient denies cough, wheezing, shortness of breath, or sputum production.

Cardiovascular:

Patient reports a history of high blood pressure since the last 20 years. Denies

chest pain, pressure, palpitation, dizziness, or blue/cold fingers and toes.

Patient is unaware of exercise intolerant due to no participation in exercise.

Gastrointestinal:

Patient denies nausea, vomiting, constipation, diarrhea, coffee grounds in vomit,

dark tarry stool, bright red blood in stool, early satiety, or bloating. Denies

jaundice, gallbladder or liver problems.

Urinary:

Patient denies frequency, incontinence, dysuria, hematuria, or recent flank pain.

Genital:

Patient denies vaginal discharge, itching, sores, lumps, sexually transmitted

infections and treatments. G6 P6. Denies any sexual practices.

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Musculoskeletal:

Patient reports bilateral knee pain. She describes the pain as stiff and achy which

occurs in the mornings for 15-20 minutes. The pain in the right knee is worse

compared to the left. The right knee pain radiates down to the ankle. Patient also

reports swelling in both knees and occasional swelling in her finger knuckles.

Patient also reports limited range of motion. Patient denies any systemic

symptoms with the joint pain such as fever, chills, rash, anorexia, weight loss, or

weakness. Patient also denies neck, lower back pain, muscle pain, or gout.

Psychiatric

Denies nervousness, tension, mood, including depression, memory change,

suicidal ideation, suicide plans or attempts. Denies past counseling psychotherapy, or psychiatric conditions

Neurologic

Patient denies changes in mood, attention, or speech; changes in orientation,

memory, insight, or judgment; headache, dizziness, vertigo, fainting, black-outs;

weakness, paralysis, numbness or loss of sensation, tingling or “pins and

needles, tremors or other involuntary movements, or seizures.

Hematologic:

Denies anemia, easy bruising or bleeding, past transfusion, or transfusion

reactions.

Endocrine:

Denies “thyroid trouble”, heat or cold intolerance, excessive sweating, excessive

thirst or hunger, polyuria, change in glove or shoe size. Patient reports, “I do

prefer summer over winter.”

C. Physical Exam (Objective) (O)

1. Vital Signs:

Left Arm BP: 138/86

Pulse: 82 regular rhythm

Respiration 12 unlabored

Temperature 98.6 F

Weight is 184 lbs

2. General assessment – Ms. Johnson is alert and oriented to

place, time, and situation. She communicates well and is a

reliable historian. She is sitting quietly and appears in no obvious

distress. Ms. Johnson appears to be her stated age.

3. Document physical examination findings of systems

appropriate to chief complaint (include pertinent positive and

negative findings

Positive findings:

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 Bony enlargement of her knees. There is evidence of a small

effusion (fluid) in the right knee. Both knees exhibit crepitus,

a grinding or crackling noise or sensation felt over the joint.

 The medial joint line of both knees is tender upon palpation.

 Some of her finger joints are enlarged (both proximal and

distal interphalangeal joints)

 She has limited range of motion in her knees, they can only

be flexed to 90 degrees. She cannot completely straighten

her knees. Her ability to flex and extend at the hips is also

diminished slightly.

 She has limited range of motion in her fingers.

Negative findings:

 She has normal musculoskeletal stability.

II. ASSESSMENT (Medical Diagnosis) – Your differential diagnoses

List of Differential Diagnoses

 Differential Diagnosis #1: Osteoarthritis:

Osteoarthritis is a degenerative joint disease in which there is a slow, progressive

loss of joint cartilage from mechanical stress. The joints that are affected in the

disease can be the knees, hips, hands, cervical and lumbar spine, and wrists.

The pain in osteoarthritis occurs in the morning lasting a brief amount of time.

With the pain, small joint effusions are present with bone enlargement. Risk

factors in developing osteoarthritis is obesity and genetic factors (Bickley &

Szilagyi, 2017, pp. 696-697). Diagnostic studies that confirm the diagnosis of

osteoarthritis are films that show “progressive changes, including diminishing

joint space, sclerosis, and osteophyte formation (Goolsby & Grubbs, 2019, p.

443).”

Ms. Mable Johnson has many positive findings that indicates this disease. Ms.

Johnson has had pain in her knees for 5 years but has gotten worse over the

years. The pain is in both knees which occurs in the morning, and it last for

about 15 to 20 minutes. Occasionally, Ms. Johnson has pain in her hands along

with the knee pain. Along with the pain, Ms. Johnson has swelling in her knees

and finger knuckles. Ms. Johnson is also obese, and her mother had a history of

arthritis. During her physical examination, it was noted that Ms. Johnson has

bony enlargement of her knees, and there is an evidence of small effusion

(fluid) in the right knees. Some of her fingers joints are enlarged. To

confirm the diagnosis, the left and right knee x-ray shows significant narrowing

of the medial joint space of left knee with sclerosis and osteophytes.

 Differential Diagnosis #2: Gout - Significant positive & negative findings

Gout is an inflammatory reaction that results from microcrystals within a joint

space. The pain is usually located on the big toe. The onset of the pain is sudden

usually at night, the pain is confined to one joint, along with the pain there is

tenderness, hot and red joints, stiffness is usually not present, and fever may

also be present (Bickley & Szilagyi, 2017, pp. 696-697). To confirm the diagnosis

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of Gout, “films are generally negative unless the condition has persisted for

a long period. In this case, films may reveal “punched-out” lesions of the bone.

The uric acid level is elevated. Joint aspirate will reveal crystals. There may

be a mild increase in white blood cells, and sedimentation rate is increased

(Goolsby & Grubbs, 2019, p. 446).”

Ms. Mabel Johnson has many negative findings for the differential diagnosis of

Gout. Ms. Johnson describes her pain in her knees as stiff and achy, which

occurs in the morning for a brief amount of time. In gout, the pain is usually

confined in one joint which occurs suddenly at night, and there is no stiffness

present. Ms. Johnson also does not complain of hot, red joints or fever. The test

show a normal uric acid level, normal ESR, normal synovial fluid analysis, and

normal CBC.

 Differential Diagnosis #3: Rheumatoid Arthritis - Significant positive & negative

findings

Rheumatoid Arthritis is a chronic inflammation of the synovial membranes. The

common location affected for rheumatoid arthritis are the hands and

symmetrical in nature. The pain is onset is usually fast. Along with the pain,

swelling, warmth of the joints is present. Redness of the joints is almost

always present. Stiffness is usually present for an hour in the mornings. The

diagnostic studies that help to confirm the diagnosis are a positive antinuclear

antibody (ANA) and anticitrullinated protein (anti-CP) autoantibodies. The scans

show a loss of joint space and erosions. Also, normocytic hypochromic

anemia is present with elevation of sedimentation rate and C-reactive protein.

Ms. Mabel Johnson has many negatives and some positives for the differential

diagnosis of rheumatoid arthritis. Some positive findings are that Ms. Mabel

Johnson has pain in both her knees in the morning and stiffness is present.

Negative findings are that Ms. Mabel Johnson does not complain of redness,

warmth of the joints. Also, her pain was a gradual onset which occurs briefly

in the mornings. Patients with rheumatoid arthritis, the pain is usually fast and

last about an hour. Diagnostic studies show a normal ANA and a normal CBC

which rules out the differential diagnosis of rheumatoid arthritis.

 Differential Diagnosis # 4 Septic Arthritis - Significant positive & negative findings

Septic Arthritis is an infection of the joint. Symptoms that are associated with the

Septic Arthritis are fever, swollen, red and warm joints. In Septic Arthritis, the

joints that are commonly affected are the knees but the hips, shoulders can also

be affected. The diagnosis of Septic Arthritis is made from joint fluid analysis

which alters the color, volume, and makeup of the fluid. Along with the joint

fluid analysis, a CBC, and imaging test can help confirm the diagnosis (Mayo

Clinic Staff, 2021).

Ms. Mabel Johnson has many negative and few positive findings for the

differential of septic arthritis. Ms. Johnson does have swollen joints but she does

not present with redness or warmth of the affected joints. Ms. Johnson also does

not have a fever that occurs most commonly with septic arthritis. The diagnostic

tests show that the synovial fluid analysis was normal, and the CBC was also

normal. The x-rays did not show any evidence of septic arthritis.

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 Differential Diagnosis #5: Calcium pyrophosphate dehydrate deposition disease

(CPPD)/pseudogout - Significant positive & negative findings

Calcium pyrophosphate dehydrate deposition disease (CPPD)/pseudogout is a

form of arthritis that occurs from deposit of calcium pyrophosphate crystals. The

signs and symptoms that appear with pseudogout are pain, stiffness, redness,

warmth, and swelling. It usually affects the knees and the wrists, and it usually

targets one joint at a time. The diagnosis of pseudogout can be made by doing a

synovial fluid analysis and x-rays, but it is confirmed with finding calcium

pyrophosphate dehydrate crystals on the synovial fluid analysis (“Pseudogout

(CPPD): What Is It, causes, & treatment”, 2020)

.

Ms. Mabel Johnson has many negative findings and a few positive findings.

Some positive findings for this differential diagnosis is that Ms. Johnson has

pain, stiffness, and swelling in her knees, but does not have warmth or redness

in her knees. The test that were conducted showed a normal synovial fluid

analysis which helps rule out this diagnosis.

List of Other diagnoses: - these are clear from what the patient told you –

Hypertension (since the past 20 years)

Peptic Ulcer Disease (GI bleed from Ibuprofen 4 years ago)

Chronic Kidney Disease

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References

Bickley, L. S. & Szilagyi, P. G. (2017). Bates’ guide to physical examination and history

taking, 12th ED. Wolters Kluwer: Philadelphia, PA.

Goolsby, M.J., & Grubbs, L. (2019). Advanced Assessment: Interpreting Findings and

Formulating Differential Diagnoses (4th Eds.). Philadelphia, PA: FA Davis

Mayo Clinic Staff. (2021, February 5). Septic arthritis.

https://www.mayoclinic.org/diseases-conditions/bone-and-joint

infections/symptoms-causes/syc-20350755.

Pseudogout (CPPD): What Is It, causes, & treatment. Cleveland Clinic. (2020).

https://my.clevelandclinic.org/health/diseases/4756-calcium-pyrophosphatedihydrate-deposition-disease-cppd-or-pseudogout.

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