Event 1: Meet Marty

Marty has had a ten year history of left knee pain that has significantly impacted her quality of life. She is finally considering knee surgery. Let's join her as she navigates the health care system seeking relief from her pain.


Review Marty's Chart


Ms. Marty James is a 55-year-old African American female with a 10 year history of left knee pain. She and her husband live in St. Louis in a middle-class neighborhood. She has private health insurance that is fairly good, but does have a high deductible to meet every year.

She has previously trialed Orthovisc 30mg X 4 weekly injections (ineffective), physical therapy X 2 courses (ineffective), transcutaneous nerve stimulation (ineffective), heat and ice application (partially effective), intra-articular triamcinolone 5mg every 4 months (partially effective lasting 2-3 weeks).


  • Osteoarthritis of knee (L>R) X 10 years
  • Chronic low back pain X 5 years
  • Hypertension X 12 years
  • Depression X 3 years


Current Meds

  • Acetaminophen 500mg Q6HPRN (uses all 4 doses daily)
  • Tramadol 50mg tabs 1 tab Q6HPRN (tries not to take but usually does)
  • Meloxicam 15mg PO QAM
  • Fluoxetine 40mg PO QAM
  • Amlodipine 10mg QHS

Previous Meds

  • Venlafaxine XR 150mg QAM
  • Hydrocodone/Acetaminophen 10-325mg 1 tab q6-8h PRN
  • Naproxen 500mg 1 tab Q12 PRN
  • Ibuprofen 800mg 1tab Q8 PRN
  • HCTZ 25mg 1 tab QAM


  • Cesarean section at 22 years old
  • Cholecystectomy 1998


  • Mother deceased breast CA at 64
  • Father alive and well at 77 with Type 2 DM and hypertension
  • Brother alive and well at 49  years old with hypertension and polysubstance abuse (EtOH and cannabis)


  • Previous smoker (20 pack year, quit 5 years ago)
  • Denies EtOH
  • Denies rec drug use
  • Reports moderate exercise (swimming) 2 times weekly, would prefer to walk with friends
  • Consumes 2 to 3 cups of coffee daily
  • Works fulltime as a supervisor at a warehouse


  • CNS
    • Denies HA, visual changes
    • Denies fever, runny nose
  • CV/Pulm
    • Denies chest pain, SOB, palpitations
  • GI/GU
    • Denies N/V/D/C urinary retention, or incontinence
  • Ext
    • Denies swelling
  • Musculoskeletal
    • Pain and stiffness in left>right knee and lower back


  • Gen
    • WDWN AAF in NAD, A&O X 3
    • PERRLA, EOMI, no cervical lymphadenopathy, thyroid anodular and symmetric
  • CNS
    • CN II-XII grossly intact, DTR + 3 bilaterally
  • CV/Pulm
    • RRR, S1/S2, non m/g/r, no rales, crackles, wheezes, CTA
  • GI/GU
    • Positive BS X 4 quadrants, no rebound tenderness or guarding
  • Ext
    • No c/c/e
  • Musculoskeletal
    • Pain on palpation of left knee medially, laterally, and anteriorly. Negative anterior/posterior drawer, positive Apley and McMurray. + crepitus on flexion


Xray of knee
Image of knee
  • Examination
    • Left knee 3 views
  • Reason for exam
    • Pain
  • Comparison
    • 2 prior films
  • Technique
    • 3 views of the left knee were obtained
  • Findings
    • There is narrowing of the patellofemoral and medial joint compartments. Findings consistent with osteoarthritis. There is no indication of fracture. No osseous destructive lesions. No definite joint effusion.
  • Impression
    • Osteoarthritis. No acute fracture.









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