Andrew Chen is a 14-year-old male presenting with pain and swelling in his right ankle following a basketball injury, with an underlying history of chronic ankle pain and severe obesity.
In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final complex diagnosis involving osteochondritis dissecans, juvenile idiopathic arthritis, and gout. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this challenging pediatric musculoskeletal case simulation.
Only a few hours left for your iHuman case study?
Send us the brief, and we’ll deliver it fast
Andrew Chen iHuman Case Overview (Doorway Information)
Patient Overview: Andrew Chen is a 14-year-old male presenting with a chief complaint of “pain and swelling in the right ankle” following a basketball injury. He was playing in a basketball game last night when he drove for a layup, stepped on his opponent’s foot and fell. However, this acute presentation overlays a more complex history of chronic right ankle pain that began approximately one year before presentation and has been refractory to conservative treatments.
Key Background Information:
- Age/Gender: 14-year-old male
- Chief Complaint: Pain and swelling in right ankle
- Acute trigger: Basketball injury (stepped on opponent’s foot)
- Chronic history: Right ankle pain for approximately 1 year
- Pain Characteristics: Medial ankle location, activity-related, with intermittent swelling
- Associated symptoms: Bilateral restricted ankle dorsiflexion, worse on right
- Significant History: Severe obesity (BMI 47.4), failed conservative treatments
- Current Medications: Occasional ibuprofen
- Physical findings: Unable to bear weight, tenderness over medial malleolus
- Complex outcome: Multiple concurrent diagnoses including OCD, JIA, and gout
- Risk factors: Severe obesity predisposing to adult-onset conditions
The patient appears in mild distress due to pain, is severely obese, and unable to bear weight on the affected ankle. His presentation demonstrates the complexity of diagnosing multiple concurrent conditions in pediatric patients, making this an excellent case for learning systematic musculoskeletal assessment and complex diagnostic reasoning skills.
Andrew Chen (14 y/o male) – Ankle Pain Assessment
- CC: Pain and swelling in right ankle
- MSAP: Acute ankle injury superimposed on chronic medial ankle pain with bilateral dorsiflexion restriction, severe obesity (BMI 47.4), and ultimate multiple diagnoses
- Associated bilateral restricted ankle motion and intermittent swelling
- History: Severe obesity, chronic ankle pain, failed conservative treatments, family history negative for autoimmune disease
- Complex diagnostic course requiring multiple specialties
History Questions:
− How can I help you today?
− Tell me about what happened to your ankle last night
− When did you first start having ankle problems?
− Any other symptoms we should discuss?
− Do you have any allergies?
− Are you taking any OTC or herbal medications?
− Any new or recent changes in medications?
− What does the pain in your ankle feel like? (aching, sharp, throbbing, stabbing, burning)
− How severe (scale 1−10) is the pain in your ankle?
− Does anything make the pain in your ankle better or worse?
− What are the events surrounding the start of your chronic ankle pain?
− Is there a pattern to your ankle pain?
− Have you had any trauma to your ankle before this?
− Does the pain in your ankle radiate someplace else? Where?
− Can you bear weight on your ankle?
− Does your ankle ever lock or catch?
− Does the pain get worse with activity?
− Does your ankle pain awaken you from your sleep?
− Have you noticed any swelling in your ankle or other joints?
− Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats?
− Do you have pain or stiffness in any other joints?
− Does anything make your joint stiffness better or worse?
− How long does your morning stiffness last?
− Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite?
− Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling?
− Do you have problems with: N/V, constipation, diarrhea, change in bowel habits?
− How is your overall health? − Tell me about your sports activities and exercise
− Tell me about your typical diet − Any family history of arthritis or joint problems?
Physical Exam:
− Vitals: pulse, BP, respirations, temperature
− Height and weight (BMI calculation)
− General appearance and nutritional status
− Extremities: Visual inspection of both ankles and lower extremities
− Ankle examination: o Visual inspection for swelling, deformity, erythema o Palpate ankle structures (medial/lateral malleoli, joint lines, tendons) o Range of motion testing (dorsiflexion, plantarflexion, inversion, eversion) o Special tests (anterior drawer, talar tilt, squeeze test) o Weight-bearing assessment − Musculoskeletal: o Examine other joints for signs of polyarticular involvement o Assess gait if patient able to ambulate o Spine examination for range of motion − Neurological: sensation and motor strength in affected extremity
Assessment note: A.C. is a 14 y/o severely obese male (BMI 47.4) presenting with acute ankle injury superimposed on chronic right ankle pain. His chronic symptoms began approximately one year ago but did not respond to immobilization, physical therapy, or prolonged rest. The pain is located at the medial side of the ankle, is worse with activity, and is accompanied by intermittent swelling. Physical exam reveals bilateral restricted ankle dorsiflexion, worse on the right, with tenderness over the medial malleolus. Initial imaging showed evidence of osteochondritis dissecans, but subsequent clinical course revealed multiple concurrent conditions including JIA and gout.
Diagnostic workup: Initial radiographs showed healing OCD lesion, later MRI more consistent with chondroblastoma versus inflammatory process
Complex diagnosis: Multiple concurrent conditions – OCD, JIA (RF+ polyarticular), and gout with elevated uric acid levels (11.7-13.5 mg/dL)
Diagnosis:
- Acute ankle sprain
- Osteochondritis dissecans of the ankle
- Juvenile idiopathic arthritis (RF+ polyarticular)
- Gout (associated with severe obesity)
Plan:
− Immediate management with RICE protocol and non-weight bearing
− Comprehensive diagnostic workup including CBC, ESR, CRP, uric acid, RF, anti-CCP − Ankle radiographs and MRI for detailed evaluation
− Rheumatology consultation for polyarticular symptoms and JIA management
− Orthopedic consultation for OCD management and possible arthroscopy
− Initiate anti-inflammatory therapy with naproxen
− Consider methotrexate for JIA management − Weight management counseling and nutritional consultation − Physical therapy for range of motion and strengthening
− Long-term monitoring for uric acid levels and gout management − f/u in 2-3 weeks with earlier return for worsening symptoms
Andrew Chen SOAP Note
Patient: Andrew Chen Subjective Data
CC: 14-year-old male presents with “pain and swelling in right ankle”
HPI: 14-year-old severely obese male presents with acute exacerbation of chronic right ankle pain following basketball injury. Patient was playing basketball when he drove for a layup, stepped on opponent’s foot and fell. He had his trainer look at his ankle and wrap it with an ACE wrap when it happened. He took the ACE wrap off last night to shower and forgot to put it back on. He did ice and elevate his leg when he laid down.
He is unable to bear weight at this time due to the pain. Patient reports underlying chronic right ankle pain that began approximately one year ago following initial sports injury but has been refractory to multiple treatments including immobilization, physical therapy, and prolonged rest. The chronic pain is located at the medial side of the ankle, is worse with activity, and is accompanied by intermittent swelling. He takes ibuprofen occasionally at night which provides modest relief. Upon physical examination, the patient is severely obese with BMI of 47.4 and has bilateral restricted ankle dorsiflexion, worse on the right.
Medications: Occasional ibuprofen for pain relief
Allergies: (medication, environmental, food) The patient denies any medication, environmental or food allergies
PMH: Previous medical history was unremarkable. Denies other chronic medical conditions.
LNMP/OB History (if indicated): Not applicable
PSH: Denies any surgical or dental procedures.
Sexual History (if indicated): Deferred for this exam.
Hospitalizations: None.
Health Maintenance: Reports going to primary care provider for routine check-ups.
Immunizations: Immunizations are up to date. Completed all childhood vaccines.
Family History: Family history negative for autoimmune disease including JIA. No known family history of arthritis or joint problems.
Substances (Tobacco, alcohol, illicit drugs, caffeine): The patient denies illicit drug use, tobacco, or alcohol use. Reports mild caffeine intake.
Home environment: The patient lives with family and reports a safe home environment.
Employment type: Full-time student. Active in basketball and other sports activities.
Diet: Reports poor dietary habits contributing to obesity. Frequent fast food and high-calorie intake.
Sleep: Sleeps adequately and denies ankle pain during sleep initially, though later develops nocturnal symptoms.
Exercise: Very active in sports including basketball. High level of athletic participation.
Safety: Reports feeling safe at home. Denies history of physical or verbal abuse.
Objective Data
ROS: (Perform an appropriate ROS based on the C/C and HPI; documented in i-Human assignment; performed in final focused exam
General: Reports usual state of good health aside from ankle problems. Denies fever, chills, recent weight gain or loss initially, though weight management becomes a concern. Eye contact is appropriate with clear speech. Severely obese with BMI of 47.4.
Skin, Hair and Nails: Denies any recent lesions, rashes, changes in texture, or moles.
HEENT: Denies headaches, blurry vision, or vision changes. Denies ear problems or ear pain. Denies sinus problems or pain. Denies nasal congestion, cough, runny nose, sore throat, or sputum production. Denies difficulty swallowing, pain in the jaw or neck.
NECK: Denies pain or stiffness of the neck. Denies swollen glands/lumps in neck.
Thorax and Lungs: Denies shortness of breath or respiratory symptoms. Denies history of lung disease, allergies, or asthma. Denies wheezing, trouble catching breath.
Cardiovascular: Denies chest pain, palpitations, or cardiovascular symptoms. No known cardiac history.
Peripheral Vascular: Denies upper extremity symptoms. Lower extremity significant for ankle pain and swelling as described. Denies leg cramps, skin ulcers or varicose veins.
Abdomen: Denies nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stools, bright red blood in bowel movements, bloating or early satiety.
Genitourinary: This exam was deferred.
Metabolic/Hematologic: Denies thyroid disease, heat/cold intolerance, excessive hunger, thirst initially, though later develops symptoms potentially related to metabolic issues. Denies history of diabetes initially.
Psychiatric: Denies history of nervousness, depression, lack of interest, sadness, memory loss, mood changes, or hearing voices. Denies difficulty falling or staying asleep initially. Denies ideas of self-harm or suicidal ideation.
Musculoskeletal: Reports chronic right ankle pain with acute exacerbation, located at medial aspect. Later develops polyarticular symptoms affecting knees, elbows, wrists, MCPs and PIPs. Reports bilateral restricted ankle dorsiflexion, worse on right. Eventually develops limited range of motion in multiple joints and difficulty ambulating.
Neurologic: Denies history of stroke, syncope, seizures, or frequent/incapacitating headaches. Denies tremors, decreased alertness, or loss of sensation.
Vital Signs: Temperature: Normal, Pulse: Normal, BP: Normal, Respirations: Normal Height: 173 cm, Weight: 142 kg, BMI: 47.4
Assessment
General: Severely obese adolescent male, appears stated age, alert, and oriented. Initially in mild distress due to ankle pain, later develops more systemic symptoms.
Skin, Hair and Nails: Skin is warm and dry with no lesions noted. Thickness and distribution pattern is typical for patient’s gender and age. Capillary refill is less than 3 seconds in fingers and toes.
HEENT: The head is normocephalic and atraumatic. Normal appearing external ears, nose, and throat examination. Pupils equal and reactive to light.
NECK: No lesions, or edema noted. No stiffness or pain noted. Full range of motion of the neck noted. No pathologically enlarged lymph nodes noted.
Thorax and Lungs: Thorax is atraumatic, without deformity. Normal symmetrical respiratory effort. All lung fields are clear to auscultation. No wheezing, crackles or stridor noted.
Cardiovascular: Normal heart rate and rhythm, normal S1 and S2 without murmur, click, gallop, or rub.
Peripheral Vascular: Extremities are warm. Dorsalis pedis and posterior tibial pulses intact bilaterally. Significant swelling noted in right ankle.
Abdomen: Abdomen is soft to palpation and nontender. Bowel sounds normoactive in all 4 quadrants. No masses or bruits noted.
Genitourinary: Deferred for this exam.
Psychiatric: Affect and speech is clear and appropriate. Calm emotional state initially, though later develops frustration with chronic symptoms.
Musculoskeletal: Severely obese adolescent with acute right ankle injury. Bilateral restricted ankle dorsiflexion, worse on the right. Tenderness to palpation over the medial aspect of right ankle just anterior to the medial malleolus. Unable to bear weight on affected extremity. Later develops polyarticular involvement with pain and swelling in knees, elbows, wrists, MCPs and PIPs. Limited range of motion in affected joints and difficulty with ambulation.
Neurologic: Alert, oriented to person, place, time, and situation. Pupils equal to light and accommodation. Normal neurological examination of affected extremity limited by pain.
Differential Diagnoses
Acute ankle sprain: The patient reports acute onset of ankle pain and swelling following basketball injury with mechanism of stepping on opponent’s foot and falling. Unable to bear weight which is consistent with significant ankle sprain. However, underlying chronic symptoms suggest additional pathology.
Osteochondritis dissecans: The patient has chronic ankle pain for approximately one year that has been refractory to conservative treatments. Initial radiographs showed evidence of healing OCD lesion. This condition commonly affects adolescent athletes and can cause chronic pain and limited range of motion.
Septic arthritis: The patient presents with joint pain and swelling with warmth. However, vital signs are stable and patient appears well, making septic arthritis less likely but still requiring consideration and possible joint aspiration.
Juvenile idiopathic arthritis: Given the eventual development of polyarticular symptoms affecting knees, elbows, wrists, MCPs and PIPs, along with positive rheumatoid factor and anti-CCP antibodies, JIA becomes a strong consideration in the differential diagnosis.
Gout: Although uncommon in pediatric patients, the patient’s severe obesity (BMI 47.4) and elevated uric acid levels (11.7-13.5 mg/dL) make gout a consideration. With increasing pediatric obesity, adult conditions are being seen more frequently in younger patients.
Most Likely Diagnosis: Complex case with multiple concurrent diagnoses including acute ankle sprain, osteochondritis dissecans, juvenile idiopathic arthritis (RF+ polyarticular), and gout. The patient’s severe obesity predisposed him to adult-onset conditions typically not seen in pediatric patients.
Plan
Health Promotion: (appropriate screening, disease prevention, and health promotion according to the patient’s age, gender, and identified risk factors…not diagnosis specific)
✓ Weight management counseling and nutritional consultation
✓Regular monitoring of growth and development
✓ Encourage appropriate physical activity with joint protection
✓ Regular follow-up for chronic conditions managementScreening
✓ Metabolic screening given obesity (diabetes, metabolic syndrome)
✓ Regular monitoring of inflammatory markers and uric acid levels
✓ Bone health assessment given chronic inflammatory conditions
✓ Regular ophthalmologic screening if on methotrexate
Immunizations
✓ Age-appropriate immunizations including annual influenza vaccine
✓ Consider live vaccine precautions if starting immunosuppressive therapy
Complete Step-by-Step Guide to Writing the Andrew Chen iHuman Case Study
Completing the Andrew Chen iHuman case requires a systematic approach that recognizes the complexity of multiple concurrent diagnoses in a severely obese adolescent patient. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.
Step 1: Pre-Case Preparation and Initial Approach
Before diving into the case, take a moment to review the doorway information and formulate your initial clinical approach.
Key Information to Note:
- 14-year-old male with ankle pain and swelling
- Recent basketball injury but chronic underlying symptoms
- Consider immediate orthopedic causes but also systemic conditions
- Adolescent athlete population considerations
Initial Clinical Mindset: Approach this case with both acute injury and chronic conditions as considerations. The combination of acute trauma and chronic symptoms in an adolescent athlete requires systematic evaluation of multiple potential diagnoses.
Step 2: Conducting the History of Present Illness (HPI)
The HPI is crucial for distinguishing between acute injury and chronic pathology. Use the OLDCARTS method systematically:
Onset: Ask about both the acute injury and chronic symptoms
- Key points to elicit: Recent basketball injury mechanism, chronic ankle problems for approximately one year
Location: Determine the exact location and any pattern of spread
- Target response: Medial ankle pain initially, later polyarticular involvement
Duration: Distinguish acute vs. chronic timelines
- Important detail: Acute injury last night, chronic symptoms for one year
Character: Detailed description of pain quality and associated symptoms
- Critical descriptors: Aching pain, activity-related, with swelling
Aggravating factors: What makes symptoms worse
- Essential findings: Activity, weight-bearing, sports participation
Relieving factors: What provides relief
- Key response: Rest provides some relief, ibuprofen gives modest improvement
Timing/Treatment: Pattern and previous treatments tried
- Important pattern: Chronic symptoms refractory to conservative treatments including immobilization, physical therapy, and rest
Severity: Pain scale rating for both acute and chronic symptoms
- Typical response: Acute pain 7-8/10, chronic pain variable with activity
Associated Symptoms:
- Ask specifically about: other joint involvement, morning stiffness, constitutional symptoms, dietary factors
Step 3: Review of Systems (ROS)
Conduct a thorough but focused ROS, paying special attention to musculoskeletal and constitutional systems:
Musculoskeletal:
- Joint pain, stiffness, swelling (beyond chief complaint)
- Morning stiffness duration and quality
- Other joint involvement patterns
- Functional limitations and activity tolerance
Constitutional:
- Fever, chills, fatigue
- Weight changes, appetite changes
- Sleep patterns and quality
Integumentary:
- Rash, skin changes
- Joint erythema or warmth
Gastrointestinal:
- Dietary habits (relevant to obesity and gout risk)
- Any relationship between diet and symptoms
Step 4: Past Medical History, Social History, and Family History
Past Medical History:
- Previous injuries or joint problems
- Growth and development history
- Previous hospitalizations or surgeries
- Immunization status
Family History:
- Family history of arthritis, autoimmune conditions
- Family history of gout or metabolic conditions
- Genetic predispositions
Social History:
- Sports participation and activity level
- Dietary habits and nutritional assessment
- School performance and social functioning
- Weight history and body image concerns
Step 5: Physical Examination Strategy
Perform a comprehensive musculoskeletal-focused physical exam:
Vital Signs and General:
- Height, weight, BMI calculation (critical finding)
- General appearance and nutritional status
- Pain assessment and functional status
Musculoskeletal Examination:
- Inspection: Both ankles for swelling, deformity, skin changes
- Palpation:
- Specific ankle structures (malleoli, joint lines, tendons)
- Areas of point tenderness
- Assessment of warmth and swelling
- Range of Motion:
- Active and passive range of motion
- Bilateral comparison (key finding of bilateral restriction)
- Dorsiflexion, plantarflexion, inversion, eversion
- Special Tests:
- Anterior drawer test for ankle stability
- Talar tilt test
- Squeeze test for syndesmosis
- Weight-bearing assessment
- Additional Joint Examination:
- Systematic evaluation of other joints for polyarticular involvement
- Assessment for signs of inflammatory arthritis
Neurological Assessment:
- Sensation in affected extremity
- Motor strength testing
- Deep tendon reflexes
Vascular Assessment:
- Peripheral pulses
- Capillary refill
- Color and temperature assessment
Step 6: Developing Differential Diagnoses
Propose multiple appropriate differentials recognizing the complexity of this case:
Primary Considerations:
- Acute ankle sprain
- Supporting evidence: Recent injury mechanism, inability to bear weight
- Osteochondritis dissecans
- Supporting evidence: Chronic symptoms in adolescent athlete, refractory to treatment
- Septic arthritis
- Rationale to consider: Joint swelling and warmth
- Rationale to exclude: Stable vital signs, well appearance
Secondary Considerations:
- Juvenile idiopathic arthritis
- Rationale: Polyarticular involvement, chronic symptoms
- Gout
- Rationale: Severe obesity (unusual in pediatrics but increasing recognition)
- Fracture
- Rationale to consider: Injury mechanism and pain severity
- Rationale to exclude: Based on clinical findings and imaging
Step 7: Diagnostic Test Interpretation
Develop a comprehensive diagnostic approach:
Initial Imaging:
- Ankle radiographs: Multiple views to assess for fracture, OCD lesions
- Expected findings: Evidence of healing OCD lesion
Advanced Imaging:
- MRI ankle: Better visualization of cartilage and soft tissue
- Expected findings: Findings consistent with chondroblastoma vs. inflammatory process
Laboratory Studies:
- CBC: Rule out infection, assess for inflammatory conditions
- ESR/CRP: Inflammatory markers (expect elevation)
- Rheumatoid factor: Expect positive result
- Anti-CCP antibodies: Expect positive result supporting JIA diagnosis
- Uric acid level: Critical test given obesity (expect elevation 11.7-13.5 mg/dL)
Clinical Correlation: Use test results to support multiple concurrent diagnoses rather than a single condition.
Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)
Recognize Complex Diagnosis: Multiple concurrent conditions affecting the same patient
- Acute ankle sprain (immediate injury)
- Osteochondritis dissecans (chronic structural problem)
- Juvenile idiopathic arthritis, RF+ polyarticular (systemic inflammatory condition)
- Gout (metabolic condition related to obesity)
MSAP Selection: Choose the most clinically significant condition requiring immediate management, likely the acute ankle sprain or the newly diagnosed JIA depending on presentation severity.
Step 9: Comprehensive Management Plan
Develop a multi-faceted treatment approach addressing all conditions:
Immediate Management:
- RICE protocol for acute ankle injury
- Non-weight bearing with crutches
- Pain management with NSAIDs
Systemic Management:
- Rheumatology consultation for JIA management
- Initiate disease-modifying therapy (naproxen, consider methotrexate)
- Monitor for treatment response and side effects
Orthopedic Management:
- Orthopedic consultation for OCD management
- Consider arthroscopy if conservative treatment fails
- Long-term monitoring of joint function
Metabolic Management:
- Weight management counseling
- Nutritional consultation
- Monitor and manage elevated uric acid levels
- Consider allopurinol for gout management
Long-term Follow-up:
- Regular monitoring of all conditions
- Functional outcome assessments
- Quality of life considerations
- Transition planning to adult care
Step 10: Documentation and Submission Tips
Writing Your Summary:
- Create a comprehensive summary explaining the complex diagnostic process
- Include how multiple conditions can coexist
- Cite specific assessment findings and lab correlations
- Discuss the significance of obesity in pediatric patients
Key Documentation Elements:
- Assessment Statement: Brief patient summary acknowledging complexity
- Clinical Reasoning: Explain how you arrived at multiple diagnoses
- Evidence Correlation: Link physical findings to test results for each condition
- Management Rationale: Justify multi-specialist approach
Final Submission Checklist:
- ✓ Complete history addressing both acute and chronic symptoms
- ✓ Comprehensive musculoskeletal examination including other joints
- ✓ Appropriate differential diagnoses including complex considerations
- ✓ Recognition of multiple concurrent diagnoses
- ✓ Multi-faceted management plan addressing all conditions
- ✓ Professional documentation acknowledging diagnostic complexity
Only a few hours left for your iHuman case study?
Send us the brief, and we’ll deliver it fast
Andrew Chen iHuman Case Summary
Grading Criteria: The Andrew Chen iHuman case will evaluate you across several critical domains to ensure comprehensive pediatric musculoskeletal assessment skills with recognition of complex, multiple diagnoses. Here’s what you need to focus on to maximize your score:
(1) History Taking (Major Points):
You must ask targeted questions about both acute injury and chronic symptoms to get full credit. Essential questions include: injury mechanism (basketball, stepping on foot), chronic pain characteristics, previous treatment failures, weight history, and dietary habits. Don’t miss asking about: other joint involvement, morning stiffness, constitutional symptoms, and family history of arthritis. The rubric specifically rewards students who recognize the significance of severe obesity in pediatric patients and ask about symptoms that might suggest adult-onset conditions.
(2) Physical Examination (High Weight):
Focus your exam on comprehensive musculoskeletal assessment including bilateral comparison. Must-do components: ankle examination (inspection, palpation, range of motion, special tests), weight-bearing assessment, examination of other joints for polyarticular involvement, and BMI calculation. Pro tip: The rubric awards points for recognizing bilateral ankle restriction and systematically examining multiple joints – many students focus only on the acutely injured ankle.
(3) Differential Diagnosis (Critical for Scoring):
You need to propose multiple appropriate differentials recognizing both acute and chronic pathology. Expected differentials include: acute ankle sprain, osteochondritis dissecans, septic arthritis, juvenile idiopathic arthritis, and consideration of gout despite the patient’s young age. Scoring secret: The rubric rewards students who can recognize that severely obese pediatric patients may develop adult conditions like gout.
(4) Final Diagnosis & MSAP:
You must recognize the complexity of multiple concurrent diagnoses rather than seeking a single explanation. The case demonstrates osteochondritis dissecans, juvenile idiopathic arthritis, and gout occurring simultaneously. Advanced scoring requires understanding how obesity predisposes pediatric patients to adult-onset conditions.
(5) Management Plan (Heavily Weighted):
The rubric expects comprehensive management addressing all identified conditions including: immediate injury management, rheumatology consultation, orthopedic evaluation, weight management counseling, and long-term monitoring plans. High-scoring responses mention: need for disease-modifying therapy for JIA, consideration of surgical intervention for OCD, and metabolic management for gout.
(6) Clinical Reasoning:
Demonstrate understanding of how multiple conditions can coexist and complicate diagnosis. Bonus points for: recognizing the delay in diagnosis that occurred in this case, understanding the significance of obesity in changing disease patterns in pediatrics, and acknowledging the complexity of managing multiple concurrent conditions.
Example of a High-Scoring Clinical Summary
Here’s how a top-performing student might document this case:
Patient Summary – Andrew Chen
Situation: 14-year-old severely obese male (BMI 47.4) presenting with acute ankle injury superimposed on chronic refractory ankle pain with subsequent diagnosis of multiple concurrent conditions.
Background: Significant risk factors including severe obesity predisposing to adult-onset conditions. Chronic ankle pain for one year refractory to conservative treatments including immobilization, physical therapy, and rest. Initial presentation following basketball injury with inability to bear weight.
Assessment: Physical examination notable for bilateral restricted ankle dorsiflexion worse on right, medial ankle tenderness, and severe obesity. Initial radiographs showed healing OCD lesion. Subsequent clinical course revealed polyarticular involvement with positive rheumatoid factor and anti-CCP antibodies. Elevated uric acid levels (11.7-13.5 mg/dL) confirmed concurrent gout diagnosis. Complex Diagnosis: Multiple concurrent conditions – acute ankle sprain, osteochondritis dissecans, RF+ polyarticular juvenile idiopathic arthritis, and gout.
Recommendation:
- Immediate ankle injury management with RICE protocol and non-weight bearing
- Rheumatology consultation for JIA management with naproxen and methotrexate initiation
- Orthopedic consultation for OCD management and possible arthroscopy
- Weight management counseling and nutritional consultation
- Long-term monitoring of uric acid levels and inflammatory markers
- Multi-disciplinary approach recognizing complexity of concurrent diagnoses
- Patient education regarding chronic disease management and weight reduction importance
Patient Education Provided: Explained complex nature of multiple diagnoses, importance of weight management in preventing adult-onset conditions in pediatric patients, medication compliance for chronic conditions, and clear instructions for recognizing symptom progression requiring immediate care.
Conclusion
By following this comprehensive approach to the Andrew Chen case, you’ll demonstrate the advanced clinical reasoning skills that iHuman evaluates for complex pediatric cases. Remember, success in challenging musculoskeletal cases requires recognition that patients can have multiple concurrent conditions rather than seeking a single unifying diagnosis. The key is understanding how changing demographics (increasing pediatric obesity) affect traditional disease patterns and predispose young patients to adult-onset conditions. This case teaches the importance of systematic assessment, broad differential thinking, and comprehensive management approaches. With this guide, you’re well-prepared to excel in this challenging but highly educational case simulation.
Frequently Asked Questions
What is the correct approach to Andrew Chen’s complex presentation?
Andrew Chen’s case demonstrates the importance of recognizing multiple concurrent diagnoses rather than seeking a single explanation. The correct approach involves systematic assessment leading to diagnosis of acute ankle sprain, osteochondritis dissecans, RF+ polyarticular juvenile idiopathic arthritis, and gout. Students often struggle with accepting multiple diagnoses, but this case teaches that severely obese pediatric patients can develop adult conditions like gout, and inflammatory conditions like JIA can coexist with structural problems like OCD.
What are the critical physical exam components I need to perform to score well?
Essential physical exam elements include comprehensive bilateral ankle examination (inspection, palpation, range of motion testing), assessment for other joint involvement (knees, elbows, wrists, fingers), BMI calculation and nutritional assessment, and functional evaluation including weight-bearing capacity. Many students miss points by focusing only on the acutely injured ankle and failing to examine other joints systematically. The bilateral restriction of ankle dorsiflexion is a key finding that suggests systemic rather than purely traumatic pathology.
How do I recognize and score well on the complexity of multiple diagnoses?
Success requires understanding that this case intentionally presents multiple concurrent conditions affecting the same patient. The diagnostic journey includes initial focus on OCD, subsequent recognition of polyarticular JIA, and eventual diagnosis of gout based on elevated uric acid levels. High-scoring responses demonstrate understanding of how severe obesity (BMI 47.4) predisposes pediatric patients to adult conditions and how diagnostic delays can occur when uncommon conditions are not considered in young patients.
What management interventions should I include in my treatment plan?
The comprehensive management plan must address all identified conditions including immediate ankle injury care (RICE, non-weight bearing), rheumatology consultation for JIA management with appropriate medications (naproxen, methotrexate), orthopedic consultation for OCD evaluation and possible surgical intervention, weight management counseling, nutritional consultation, and long-term monitoring of inflammatory markers and uric acid levels. Students often forget to address the obesity component, which is crucial for preventing progression of metabolic conditions like gout.