DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left knee pain and swelling.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male presents to the emergency department with a 10-hour history of painful swelling of the left knee, worse with weightbearing. The patient cannot recall any acute injury or strain or any history of blunt trauma. He has never had similar pain and swelling in the past. He has no history of gout. The patient has increased pain on the last 10 degrees of extension of the knee as well as on weightbearing and has some discomfort at night, nonweightbearing, rest.
PAST MEDICAL HISTORY: The patient is in good health, on no regular medication.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient does not smoke, drinks alcohol occasionally, and denies illicit drug use.
FAMILY HISTORY: Negative for gout. Positive for arthritis in sister.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/66, pulse 84, respirations 18, temperature 36.2 degrees, and O2 sat 95% on room air.
GENERAL: The patient is a well-developed, well-nourished (XX)-year-old who is alert and in no acute distress. The patient admits to some pain as he sits in the chair with left lower leg pain, but not weightbearing.
EXTREMITIES: Examination of his left knee reveals a joint effusion with tenderness along the joint line, which does not lateralize or localize. The knee is not warm or red. There is minimal swelling of the knee outside the joint line. Knee is stable on weightbearing. The patient has increased pain when not weightbearing on the last 10 degrees of extension, which he resists. He has full motor and sensory function distal in the left foot. Pedal pulses intact. Motor and sensory functions in the left foot are intact. The calf and thigh on the left is soft, nontender, without erythema or swelling. No red streaks, lymphangitis or redness surrounding the knee to suggest cellulitis. The knee is stable on weightbearing.
NEUROLOGIC: Cranial nerves grossly intact to inspection. The patient is alert and oriented x3. Judgment, insight, recent and remote memory all appear unimpaired.
LABORATORY AND DIAGNOSTIC DATA: Four-view x-ray showed moderate-sized joint effusion. Minimal osteoarthritic changes are seen per radiologist. We visualized the films independently and concur. Serum uric acid was 6.8.
EMERGENCY DEPARTMENT COURSE AND TREATMENT: The patient was given Motrin 800 mg by mouth with only moderate pain relief. It is unclear from history what precipitated this knee pain, which patient has never experienced before. The patient refused crutches preferring to stay nonweightbearing at home and be off work for several days.
The patient was given prednisone 60 mg by mouth. Prescription was written for prednisone 20 mg, number 10 tablets, take 2 (40 mg every 24 hours x5 days) and Lortab 7.5, number 24 tablets. The patient was advised to try Aleve 2 tablets twice a day or ibuprofen 600 mg 4 times a day for pain or inflammation. The patient was advised to start prednisone at around this time tomorrow. Follow up with us if not well in 72 hours. Use pain as a guide to weightbearing. The patient was given a referral to the orthopedic clinic.
DIAGNOSIS: Inflammatory arthritis, left knee, with moderate-sized joint effusion.
