OSCE CASE

Amanda Manzione

 

HPI: 59 yo M c/o R knee pain x 4 days

 

History Elements:

• Pain 7/10 severity, has been worsening since onset
• Difficulty ambulating since the pain began
• Pain worse with activity
• Denies any mechanism of injury or trauma
• Had an experience like this before 1 year ago on the same knee, 6 months ago on the L knee
• Pain does not radiate but sometimes he feels similar pain in his big toe
• OTC NSAIDs have not relieved the pain
• Was camping 1 week ago in the woods on Long Island
• Denies fever, n/v/d/c, headache, flu-like symptoms.

 

PE:

• Vitals: Temp 98F, HR 67 bpm, RR 16 breaths/min, BP 136/80, O2 sat 98%
• Ht 5’5”, Wt 250 lbs, BMI 41.1 (obese)
• Gen: NAD
• Lungs CTAB
• Heart normal S1/S2 no murmur
• R knee erythematous and edematous on inspection, L knee WNL
• R knee warm and firm to palpation, L knee WNL
• R knee ROM limited secondary to pain, L knee WNL
• R great toe also erythematous and swollen at MTP, otherwise R foot and L foot WNL

 

DDx

• Gout
• Osteoarthritis
• Septic Arthritis
• Trauma
• Cellulitis
• Lyme disease/other insect bite/hypersensitivity skin reaction

 

Labs:

• Joint aspirate R Knee: negative birefringent monosodium urate crystals
• CBC shows increased neutrophils
• ESR and CRP elevated
• Urate levels elevated
• Imaging with no specific finds

 

Treatment:

• Prednisone 30 mg first dose, taper down x 10 days for acute flare
• Allopurinol 300 mg daily for preventative maintenance
• NSAIDs for pain, rest

 

Patient Counseling:

• Take the steroid, Prednisone, for the next 10 days to reduce the inflammation and pain in the R knee and big toe. After this flare has subsided, begin the other medication, Allopurinol, which will help prevent further flares from occurring.
• Losing weight will be a big part of preventing gout flares and promote your overall health and well-being. Avoiding sugary drinks and alcohol can help achieve this goal