Event 1: Meet Mildred

Introduction

Meet Mildred

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Mildred
Mildred

This is Mildred.  Mildred is 83 years old and recently moved next door to her son because her old house had stairs which made it difficult to get in and out and around her house. While she lives alone, her son is closer to provide the extra help she needs with grocery shopping, cooking, and doing heavier housework. This visit is to establish care with you. Mildred was not happy with her last provider because he kept recommending she consider knee replacement surgery which she does not want.  Mildred and her son are concerned because her knee pain never goes away now.  It prevents her from doing things around the house throughout the day. An x-ray of her knee displays moderate to severe knee osteoarthritis.

Summary of Chief Complaints

  • Knee pain
  • Pain present 6 years
  • Worse past year
  • Pain interferes with using stairs and walking
  • Refractory to multiple treatments
  • X-ray consistent with osteoarthritis (OA)

Knee Osteoarthritis

The determination of knee osteoarthritis is based upon the American College of Rheumatology criteria and incorporates three approaches:

  1. clinical history and physical
  2. clinical and radiographic findings
  3. clinical and laboratory data. Each classification scheme requires knee followed by differing elements.

ACR Clinical Classification Criteria for Osteoarthritis of the Knee

Clinical criteria include knee pain and at least three of the following:

Using history and physical examination (clinical):

  • Age > 50
  • < 30 minutes of morning stiffness
  • Crepitus on active motion
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth of synovium

Using clinical and radiographic findings:

  • > age 50
  • < 30 minutes morning stiffness
  • Crepitus on active motion
  • Osteophytes on x-ray

X-ray of Knee

Osteoarthritis of the knee is supported by characteristic findings identified on X-ray which include:

  • joint space narrowing that is often asymmetric
  • the presence of osteophytes
  • the development of subchondral sclerosis

Mildred’s X-ray demonstrates multi-compartment knee osteoarthritis, including medial, lateral and patellofemoral components since characteristic findings are present in each compartment.

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An X-ray exhibiting findings consistent with diagnosis of osteoarthritis: joint space narrowing that is often asymmetric, the presence of osteophytes and the development of subchondral sclerosis.
Knee xray, modified with permission https://commons.wikimedia.org/wiki/File:Osteoarthritis_left_knee.jpg © James Heilman, MD

ACR Clinical Classification Criteria for Osteoarthritis of the Knee

The third set of knee osteoarthritis criteria use clinical and laboratory findings, pain in the knee and five of the following:

Using clinical and laboratory findings:

  • > age 50
  • < 30 minutes morning stiffness
  • Crepitus on active motion
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth of the synovium
  • Erythrocyte sedimentation rate < 40 mm/hr
  • Rheumatoid Factor (RF) < 1:40
  • Synovial fluid signs of osteoarthritis

Next: Taking Mildred's Health History

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