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Case Challenges: Patients With Joint Pain

  • Authors: Amanda E. Nelson, MD, MSCR, RhMSUS
  • CME / ABIM MOC / CE Released: 9/24/2018
  • Valid for credit through: 9/24/2019, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care physicians, orthopedists and orthopedic surgeons, rheumatologists, nurses, and pharmacists.

The goal of this activity is to increase awareness on the assessment, diagnosis, and management of patients who present with joint pain.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Clinical tools to assess/diagnose joint pain
    • Appropriate over-the-counter (OTC) analgesics for the management of joint pain
  • Have greater competence related to
    • The development of a treatment plan for select patients with joint pain


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  • Amanda E. Nelson, MD

    Assistant Professor
    Thurston Arthritis Research Center
    University of North Carolina at Chapel Hill


    Disclosure: Amanda E. Nelson, MD, MSCR, RhMSUS, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline

    Dr Nelson does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Nelson does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.


  • Karen Badal, MD, MPH

    Scientific Director, Medscape, LLC


    Disclosure: Karen Badal, MD, MPH, has disclosed the following relevant financial relationships: Owns stock, stock options, or bonds from: Kallyope, Inc.

  • Beverly Caley, JD

    Medical Writer


    Disclosure: Beverly Caley, JD has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

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Case Challenges: Patients With Joint Pain

Authors: Amanda E. Nelson, MD, MSCR, RhMSUSFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/24/2018

Valid for credit through: 9/24/2019, 11:59 PM EST


The following cases are modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will be able to see whether you answered correctly and read evidence-based information that supports the most appropriate answer choice. The questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the activity, there will be a short post-test assessment based on the material presented.

Case 1: Patient History

Leslie is a 55-year-old woman who has come to her primary care physician because of progressive pain in her left knee. She describes it as a dull aching pain that worsens with activity. She says the pain is typically worse at the end of the day compared with how it feels in the morning. When she sits for a long time or goes for a long car ride, her knee "stiffens up" and it takes her a few minutes to loosen up when she starts to move again.

Leslie reports that the pain has begun to limit her activities. She previously worked out 3 times a week at the gym, but she now finds workouts too painful. Although she can stand throughout the day at her cashier job, she has recently found that when she comes home from work in the evening, she just wants to sit in front of the television. She props her leg up on the coffee table and sometimes finds that the elevation reduces her pain. Leslie says that sometimes she notices mild swelling in her left knee; but on questioning, she denies any redness or warmth. For the swelling she uses an ice pack.

Table 1. History and Physical Examination Findings

History Findings
Medical Leslie's last annual examination was 4 months ago. At that time her HbA1c was 6.1%.
Medications None
Allergies NKDA
Surgical None
Family Mother: alive, age 80
Father: alive, age 82
No siblings
Social Married
Alcohol: social (1-3 glasses of red wine/wk)
Tobacco: none
Illicit drugs: none
Physical Examination Findings
Vital signs BP 110/78 mm Hg; pulse rate 87/min, regular; respirations 12/min; temperature 98.7⁰F; O2 saturation 95%; BMI 28 kg/m2
General Well-appearing woman in no acute distress
Skin No rash or breakdown
HEENT Normal conjunctiva and oral mucosa, good dentition
Pulmonary Normal
Heart Normal
Abdomen Normal, positive bowel sounds, no organomegaly
  • Examination of the left knee reveals a cool effusion in the superolateral aspect, without redness or warmth. There is mild crepitus. The joint is stable, with mild varus malalignment, and minimal medial joint line tenderness. McMurray's sign is negative. Range of motion is not restricted but Leslie notes mild discomfort with full extension. There is no obvious popliteal cyst
  • An examination of the nonpainful right knee reveals that it is stable with normal reflexes, normal range of motion, no crepitus, and no indication of fluid in the joint
  • No muscular tenderness is appreciated
  • Examination of the hands, wrists, elbows, shoulders, hips, and ankles is unremarkable, with full range of motion and no pain or tenderness
  • No evidence of synovitis in the small joints of the hands or feet
  • Examination of the feet is unremarkable without tenderness on metatarsophalangeal joint compression; no bunion deformities are present
Neurological AAOx3; pleasant affect
AAOx3 = awake, alert, oriented to self, location, and time; BMI = body mass index; BP = blood pressure; HbA1c = glycated hemoglobin; HEENT = head, eyes, ears, neck, throat; NKDA = no known drug allergies.
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