Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of polyarticular Juvenile Idiopathic Arthritis (JIA). Primary complaint is persistent morning stiffness in the right knee lasting [X] minutes, associated with localized swelling, warmth, and limited range of motion. Patient reports [improved/worsened] pain with activity and [no/presence of] systemic symptoms including fever, rash, or uveitis. Current medication adherence is [noted/suboptimal].
Clinical Examination Findings
Musculoskeletal exam: Right knee demonstrates [mild/moderate/severe] synovial hypertrophy, effusion, and localized warmth. Range of motion is limited to [X] degrees of flexion with [pain/crepitus] noted on passive extension. No evidence of joint deformity or contracture. Gait analysis reveals [antalgic/normal] gait pattern. Remaining joints evaluated with no active synovitis noted.
Treatment Protocol
Plan: Continue current DMARD therapy. Initiate intra-articular corticosteroid injection for the right knee to address persistent synovitis. Physical therapy referral for range-of-motion exercises and strengthening of the quadriceps. Monitor inflammatory markers (ESR/CRP) and CBC at next visit. Follow-up in [X] weeks.