IHUMAN CYRUS HORTON CASE STUDY 57 YEAR
OLD WITH ACUTE LEFT KNEE PAIN FOR 2 DAYS
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iHuman Case Study: Cyrus Horton
Patient Information
• Name: Cyrus Horton
• Age: 57
• Gender: Male
Chief Complaint
• Acute left knee pain for 2 days
History of Present Illness (HPI)
Cyrus Horton is a 57-year-old male who presents with acute
pain in his left knee that started 2 days ago. The pain began
suddenly while he was climbing stairs and has been
persistent since. The pain is described as sharp and severe,
with a rating of 8 out of 10 on the pain scale. It is localized
to the medial aspect of the knee and is aggravated by
weight-bearing and movement. Resting provides some
relief, but the pain remains constant. There is noticeable
swelling and stiffness in the knee, and he has difficulty
bending and straightening it.
Additional Symptoms:
• No redness or warmth over the knee
• No locking or giving way of the knee
• No recent trauma or injury reported
• No fever or systemic symptoms
Past Medical History (PMH)
• Hypertension (well-controlled with medication)
• Hyperlipidemia
• Type 2 Diabetes Mellitus (controlled with diet and
medication)
• Osteoarthritis in the hands and lower back
Surgical History
• Appendectomy at age 22
• Right knee arthroscopy 5 years ago for a meniscal
tear
Medications
• Lisinopril 20 mg daily
• Atorvastatin 40 mg daily
• Metformin 500 mg twice daily
• Ibuprofen 400 mg as needed for pain
Allergies
• No known drug allergies
Family History
• Father: Deceased at 75 (Myocardial Infarction)
• Mother: Alive at 80 (Hypertension, Osteoarthritis)
• Siblings: Brother with Type 2 Diabetes
Social History
• Occupation: Accountant
• Lives with wife; two adult children
• Smokes 1 pack of cigarettes per day for 30 years
• Drinks alcohol occasionally (1-2 drinks per week)
• No illicit drug use
• Diet: Balanced with occasional indulgence in fast
food
• Exercise: Minimal due to knee pain
Review of Systems (ROS)
• General: Denies weight loss, fever, chills, fatigue.
• Cardiovascular: Denies chest pain, palpitations,
shortness of breath.
• Respiratory: Denies cough, wheezing, shortness of
breath.
• Gastrointestinal: Denies nausea, vomiting,
abdominal pain, changes in bowel habits.
• Genitourinary: Denies dysuria, hematuria, urinary
frequency.
• Musculoskeletal: Reports pain and swelling in the
left knee; denies pain in other joints.
• Neurological: Denies headaches, dizziness,
weakness, numbness.
• Dermatological: Denies rashes, lesions.
Physical Examination
General
• Alert and oriented; appears in mild distress due to
pain.
Vital Signs
• Blood Pressure: 130/80 mmHg
• Heart Rate: 76 bpm
• Respiratory Rate: 16 breaths/min
• Temperature: 98.6°F
• Oxygen Saturation: 98% on room air
• BMI: 29.5 kg/m²
Musculoskeletal Examination
• Inspection:
• Left knee shows mild swelling; no erythema or
warmth.
• No deformities or visible bruising.
• Palpation:
• Tenderness over the medial joint line of the left
knee.
• No palpable effusion or crepitus.
• Range of Motion:
• Limited due to pain: flexion to 90 degrees,
extension to -10 degrees.
• Pain worsens with passive and active movement.
• Special Tests:
• Positive McMurray test indicating possible
meniscal tear.
• Negative Lachman test and anterior drawer test
(no signs of ACL injury).
• Negative varus and valgus stress tests (no signs of
collateral ligament injury).
Other Systemic Examinations
• Cardiovascular: Normal S1 and S2, no murmurs,
rubs, or gallops.
• Respiratory: Clear to auscultation bilaterally, no
wheezes or crackles.
• Abdominal: Soft, non-tender, no organomegaly.
• Neurological: Strength and sensation intact in both
lower extremities.
Differential Diagnosis
1. Meniscal Tear
2. Osteoarthritis Exacerbation
3. Gout
4. Septic Arthritis
5. Bursitis
6. Ligament Injury
Diagnostic Testing
Imaging
• X-ray of the Left Knee: To evaluate for fractures,
osteoarthritis, and any acute bony changes.
• MRI of the Left Knee: For detailed evaluation of
soft tissue structures, including menisci, ligaments, and
cartilage.
Laboratory Tests
• Complete Blood Count (CBC): To check for
infection or inflammation.
• Erythrocyte Sedimentation Rate (ESR) and CReactive Protein (CRP): To assess for inflammation.
• Joint Aspiration (if septic arthritis is suspected):
Analysis of synovial fluid for cell count, crystals, culture, and
sensitivity.
Diagnosis
• Primary Diagnosis: Meniscal Tear of the Left Knee
• Secondary Diagnosis: Osteoarthritis of the Left
Knee (contributing to chronic pain and potential
exacerbation)
Treatment Plan
Non-Pharmacological
• Rest: Avoid activities that aggravate the knee pain.
• Ice: Apply ice packs to the knee for 20 minutes
several times a day to reduce swelling.
• Compression: Use a knee brace or wrap to support
the knee.
• Elevation: Keep the knee elevated above the level
of the heart to reduce swelling.
Pharmacological
• Pain Management: Continue ibuprofen 400 mg as
needed for pain.
• Possible Corticosteroid Injection: If inflammation is
significant and not relieved by NSAIDs.
Follow-Up
• Orthopedic Referral: For further evaluation and
management, including potential arthroscopy for meniscal
repair if conservative treatment fails.
• Physical Therapy: To improve strength, flexibility,
and range of motion once the acute pain subsides.
Patient Education
• Smoking Cessation: Provide resources and support
to help the patient quit smoking, as it can affect healing and
overall health.
• Weight Management: Encourage a healthy diet
and gradual weight loss to reduce stress on the knee joints.
• Diabetes Management: Reinforce the importance
of controlling blood sugar levels to prevent complications
that can affect joint health.
By following this structured approach, you will be able to
conduct a thorough and effective evaluation and
management of Cyrus Horton’s acute left knee pain in the
iHuman case study.