11: 74-year-old woman with knee pain Flashcards
Effects of Nonsteroidal Anti-Inflammatory Medications on Symptoms of Gastroesophageal Reflux Disease
Nonsteroidal anti-inflammatory medications, like ibuprofen (Advil, Motrin), can worsen the symptoms of GERD, especially if taken on an empty stomach.
Patient’s age
Age can help narrow your differential diagnosis, as certain conditions are classically seen in certain age groups.
Children and adolescents who present with knee pain are likely to have patellar subluxation, tibial apophysitis (Osgood-Schlatter), or patellar tendonitis). Please see the Expert for additional information.
Adults are more prone to patellofemoral syndrome (a clinical diagnosis of exclusion for anterior knee pain), overuse syndromes (such as pes anserine bursitis), traumatic injuries (ligamentous sprains - anterior cruciate, medial collateral, lateral collateral - and meniscal tears) and inflammatory arthropaties, such as rheumatoid arthritis, septic arthritis, and Reiter’s syndrome.
Any previous history of trauma / injury to knee
Without a history of trauma, ligament injuries and meniscal tears are less likely. These conditions often present with acute onset of pain following trauma.
Treatments that make it better
Analgesics can often help pain, regardless of the etiology. This is less helpful in narrowing the differential diagnosis since it is so non-specific.
Actions that worsen the symptoms
Actions that worsen the symptoms are not typically helpful to narrow the differential diagnosis. However, asking the patient to perform certain maneuvers can help to assess the functioning of certain aspects of the knee as well as the extent the patient’s pain interferes with mobility. For example, the ability to squat is influenced by supporting musculature, ligaments, and the knee joint. Impaired squatting ability could be caused by effusion, knee arthritis, injury to the ligaments, etc., whereas the ability to perform the duck waddle assesses the stability of the knee and effectively rules out significant ligament instability, joint effusion, and significant damage to the meniscal cartilage.
Acute versus insidious onset of pain
The time frame of the onset of pain does not usually help narrow the differential significantly, although it can suggest whether to focus on acute (potentially traumatic) injury as a possible cause in contrast to a chronic, systemic etiology of the condition.
Monoarticular joint involvement
Knowing which joint(s) are involved can be helpful, as certain conditions have an affinity for particular joints. Gout (uric acid crystal deposition in the joint that causes severe pain) often presents in the great toe, whereas rheumatoid arthritis typically affects three or more joints, often including the hands and feet. Osteoarthritis often affects the knees, hips, and back.
Evaluation of Knee Pain
Suspected infectious process causing knee pain
»If concerned about septic arthritis or an acute inflammatory arthropathy, check a Complete Blood Count (CBC) with differential and erythrocyte sedimentation rate (ESR), though this test is non-specific.
Perform an arthrocentesis and send the fluid for cell count with differential, glucose and protein, bacterial culture and sensitivity, and polarized light microscopy for crystals. An arthrocentesis can also help differentiate between simple effusion and hemarthrosis or occult osteochondral fracture.
- -A simple joint effusion produces clear, straw-colored transudative fluid. This can happen with osteoarthritis and degenerative meniscal injuries.
- -Hemarthrosis is typically caused by a tear of the anterior cruciate ligament or a fracture. A bloody knee aspirate can be associated with a knee sprain (i.e. ACL, PCL) or acute meniscal tear. An osteochondral fracture causes hemarthrosis with fat globules.
Suspected rheumatoid arthritis causing knee pain
»If considering RA, check rheumatoid factor (RF) on blood work. This test is not very sensitive and only moderately specific for rheumatoid arthritis. It would be more helpful to as a test to rule out RF (if the test is negative), than to rule it in (if the test is positive).
Trauma causing knee pain
»To evaluate knee pain following trauma, apply the Ottawa Knee Rules to decide whether or not to order an x-ray.
Osteoarthritis Epidemiology
Epidemiology
Osteoarthritis is very common among U.S. adults, and the leading cause of disability. In fact, arthritis is expected to affect an estimated 67 million adults in the United States by 2030. Findings from a National Health Interview Survey several years ago indicated that an estimated 21.6% of the adult U.S. population (46.4 million persons) had doctor-diagnosed arthritis. Both white and black races are at equal risk for the disease.
Initial management
Exercise has been shown to improve function and decrease pain in OA. Current guidelines strongly recommend that patients with symptomatic knee OA participate in an exercise program commensurate with their ability to participate; they do not preferentially recommend aquatic or land-based exercise.
Personal Health Questionnaire (PHQ) - 2 for Depression
“During the past month:”
- “Have you often been bothered by feeling down, depressed or hopeless?”
- “Have you often been bothered by little interest or pleasure in doing things?”
Side Effects of NonSteroidal Anti-Inflammatory Drugs (NSAIDs)
> > gastrointestinal upset
decreasing the effectiveness of hypertension medications
increasing the effect of sulfonylureas
Patients who use NSAIDs chronically - taking 5,000 or more pills in a lifetime - are at an increased risk of developing end-stage renal disease. Elderly patients are at an increased risk of developing gastric ulcers when using NSAIDs chronically. NSAIDs, aspirin, and acetaminophen can all cause hepatotoxicity, and contribute to coagulopathy.
Recommended Preventive Screening for a 74-Year-Old Woman
Colorectal cancer screening by fecal occult blood test (FOBT), flexible sigmoidoscopy, or colonoscopy is recommended for patients ages 50 to 75 years old. The US Preventive Services Task Force (USPSTF) recommends against screening for colorectal cancer after the age of 75 years.
The USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup.
Patients 18 years old and older should be screened for elevated blood pressure.
The USPSTF recommends biennial screening mammography for women ages 50 to 74. They state that evidence is insufficient to make any recommendation for screening over the age of 75.
Screening Not Recommended for a 74-Year-Old Woman
A one-time ultrasound to screen for an abdominal aortic aneurysm (AAA) is recommended in men 65 to 75 years old who have any history of smoking, but the USPSTF recommends against routine screening for AAA in women.
Evidence is insufficient to make recommendations about the routine use of interventions to prevent low back pain in adults in the primary care setting.
The USPSTF strongly recommends screening women over 45 years old for lipid disorders if they are at increased risk of coronary heart disease. The USPSTF makes no recommendation about screening women over the age of 20 who do not have an increased risk of coronary heart disease.
The USPSTF recommends against screening for carotid artery stenosis in asymptomatic patients.
There is not sufficient evidence to recommend for or against routine screening for thyroid disease.
Based on USPSTF recommendations, women over the age of 65 should not be screened for cervical cancer if they have had adequate recent screening with normal Pap smears, and are not otherwise at high risk for developing the disease.
Annual Visit Preventive Medicine
- Screening tests
- Update adult immunizations
- -Tetanus - Sustitute one-time dose of Tdap for Td booster, then boost with Td every 10 years
- -Pneumococcal Polysaccharide - If > 65 years, one dose
- -Flu - One dose annually
- -Zoster - If > 60 years, one dose
Performing a Knee Exam
Have the patient put on a gown, as it is important to be able to fully examine and compare the painful knee and the non-painful knee.
Observe the patient walking and climbing onto the examination table.
Inspect both legs for erythema, edema, bruising, or atrophy of the quadriceps.
Palpate the knee joints, feeling for warmth, effusion, and point tenderness. P ay particular attention to the patella, tibial tubercle, patellar tendon, quadriceps tendon, anterolateral and anteromedial joint line, medial joint line, and lateral joint line.
Check knee range of motion by flexing and extending the knees (normal is 0 degrees extension, and 135 degrees flexion).
Assess for tenderness and range of motion on hip exam.
Lachman’s test
Assesses the stability of the anterior cruciate ligament (and not the posterior cruciate ligament)
This test is performed with the patient lying supine with the injured knee raised and slightly flexed to 30 degrees. The distal femur is stabilized by the physician with one hand, while the proximal tibia is held by the other hand. Force is applied to move the tibia anteriorly. The test is considered positive if there is excessive motion of the tibia.
Anterior and posterior drawer signs
Assess the ACL and PCL respectively
They are performed with the patient laying supine, knee bent to 90 degrees, and the foot stabilized, most easily done by the physician sitting on the foot. The physician’s thumbs are placed on the tibial tubercle, while the fingers are placed on the posterior calf. The physician then attempts to displace the tibia, either anteriorly or posteriorly. Too much motion of the tibia, or lack of a clear end-point, especially as compared to the non-painful or non-affected side, constitutes an abnormal finding.
Valgus and varus stress tests
Assess functioning of the medial and lateral collateral ligaments
These test are performed with the patient’s leg in full extension with the knee flexed to about 30 degrees. The physician places his/her hand on the lateral knee joint to apply a valgus stress to the distal tibia, or on the medial knee joint to apply a varus stress to the distal fibula. Excessive motion of the knee signifies instability of the corresponding ligament.
McMurray test
Can assess the medial and lateral menisci, though it has low sensitivity and specificity for diagnosing meniscal tears
The physician holds the patient’s heel with one hand and grasps the knee over the medial and lateral joint lines with the other hand. The patient’s knee is flexed as much as possible. The tibia is rotated either internally (tests lateral meniscus) or externally (tests medial meniscus) as the knee is extended to about 90 degrees. A varus stress (lateral meniscus) or valgus stress (medial meniscus) is applied across the knee joint while the knee is being extended. The test is positive if a clunk or click is felt, or if testing causes reproducible knee pain.
Carpal Tunnel Exam
Examine the wrist for swelling, warmth, tenderness, deformity, and discoloration.
Atrophy of the thenar eminence (the raised fleshy area on the palm of the hand near the base of the thumb) may be evident with longstanding, untreated carpal tunnel syndrome.
Tinel’s sign: Tap over the median nerve at the wrist to reproduce symptoms.
Phalen’s test: Flex wrist by having patient place dorsal surfaces of hands together in front of her for 30 to 60 seconds to reproduce symptoms.
Management of Pain Related to Osteoarthritis
Exercise (A)
Specifically water- or land-based exercise, aerobic walking, quadriceps strengthening, resistance exercise, tai chi

Reduce pain and disability
Management of Pain Related to Osteoarthritis : Acetaminophen (A)
reduces pain
First choice analgesic for both short and long-term treatment of mild to moderate pain related to osteoarthritis because of its tolerability and low side- effect profile.
Dosing is up to 4 gm per day in divided doses, though some recommend lower doses (2-3 gm/day in divided doses) if long-term use is desired.
Caution patients to be aware of coincident use of other over-the-counter or prescription medications that may contain acetaminophen so that the maximum combined daily dose does not exceed 4 gm.
Little risk of nephrotoxicity, and hepatotoxicity is a rare side effect if taken appropriately.
Management of Pain Related to Osteoarthritis: NSAIDS (A)
reduces pain
Second choice to acetaminophen because of their association with gastrointestinal side-effects, including gastritis.
Especially true in the geriatric population because of their increased risk of acute gastrointestinal bleeding, even when used in conjunction with antacids or proton pump inhibitors.
Risk of prolonged bleeding times, a potential problem if the patient is at risk for falling.
