A 55 yr old male with right knee pain and swelling
Vitals:
PR: 95/min
BP: 135/85 mmHg
RR: 22/min
Temp: 100.5

Mental Checklist of DD:
Inflammatory osteoarthritis
Septic arthritis
Lyme disease
Pseudo gout
Gout
Monoarticular rheumatoid arthritis
Traumatic knee injury
Reactive arthritis

SP’s Checklist:
History:
Asked about the onset of pain
Asked about progression
Asked about the severity of pain
Asked about intensity of pain
Asked about location
Asked about quality
Asked about radiation
Asked about associated symptoms like fever, nausea, vomiting
Asked about history of travel ( For Lyme disease endemic areas)
Asked about any history of tick bites
Asked about any rash anywhere in the body
Asked about any pain and swelling in the other joints
Asked about any recent history of febrile illness
Past History:
Asked about similar episodes in the past or joint problems
Asked about previous hospitalizations
Asked about past medical problems (Inflammatory bowel disease, Gout, Pseudogout, Rheumatoid arthritis or
Osteoarthritis)
Asked about family health
Asked about appetite and weight changes
Asked about any medications I am using
Asked about illicit drug use
Asked about smoking
Asked about alcohol intake
Asked about sexual practices
Asked about bowel and bladder habits
Asked about occupation
Examination:
Informed me
Washed hands
Draped appropriately
Checked my knee for full range of motion
Checked my knee for an effusion by ballottement or bulge method
Checked all other joints for selling and redness
Auscultated lungs and heart
Counseling:
Explained physical findings and possible diagnosis
Explained further work up (CBC, ESR, Joint aspiration)
Offered on going support
Communication Skills:
Knocked before entering the room
Introduced himself and greeted warmly
Used my name to address me
Paid attention to what I said and maintained good eye contact
Asked few open ended questions
Asked non leading questions
Asked one question at a time
Listened to what ever I said with out interrupting me in between
Used lay man’s language
Used appropriate transition sentences
Used appropriate draping techniques
Summarized the history and explained physical findings
Expressed empathy, made appropriate reassurances
Asked whether I have any concerns/ questions.
DD:
Inflammatory osteoarthritis
Septic arthritis
Pseudo gout
Monoarticular rheumatoid arthritis
Gout
Investigation:
CBC with differential, ESR
Urinalysis
Joint aspiration
Knee X-ray
ANA, Rheumatic Factor
Additional:
MRI of joint for history of trauma
Lyme titers for H/O tick bite and travel to Lyme endemic areas (New England etc)
Important points:
You may get a case of trauma to knee also. In such scenario please ask the following questions and do the following tests
along with the above check list.
Ask what was he (patient) doing at the time the pain began.
Ask are there any noises heard at the time of injury (Popping sound indicates anterior cruciate ligament injury)
Ask whether the knee was buckling or unstable.
Ask about locking and unlocking of joint ( For meniscal injury)
Perform Lachman's maneuver or Drawers test for cruciate ligament injury.
Perform McMurray's maneuver.
In the counseling explain that he needs immediate orthopedics consultation for possible meniscal or ligamental injury.