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Medical Case Study

Osteoarthritis INITIAL HISTORY: Ø 80 year old female complains of long-standing history of pain in bilateral hips, knees, and hands Ø Difficulty walking and getting up from sitting or kneeling position due to discomfort and “stiffness” Ø Reports low back pain for several years Ø Only history of fracture of right arm as a child at approximately age 9 Question 1: What other questions about her symptoms would you like to ask this patient? ADDITIONAL HISTORY >Pain in hips and knees have existed for many years, gradually getting worse. >Here today at encouragement of daughter and husband; states, I couldn’t get up when Iwas i n the flower garden. I had to crawl into the house.” >Reports joints on right side of body are most painful and troublesome >Reports weight gain of 10 pounds over past 4 months, which she attributes to decreased activity >Joints are most painful during rainy weather, in the morning, or after sitting or kneeling for a long time. Reports that joints loosen up after activity. >Farmer’s wife, active in flower and vegetable gardening, long history of horseback riding. >Reports being “thrown” 15 years ago and landing on her right hip. No known associated fracture; hasn’t ridden since. >Denies redness, swelling, or heat at the joint. >Reports low back pain which she has had for many years without recent exacerbation >Denies numbness, tingling, weakness, or shooting pain in her legs >States on rare occasions takes aspirin 325 mg for pain once or twice per week Question 2: What questions would you like to ask to ask her about her medical history? MEDICAL HISTORY: Ø Surgical history: Cholecystectomy Ø Medical history: Has given birth to 9 healthy children from 9 pregnancies Ø Seasonal affective disorderr Ø She denies history of cardiac, renal, endocrine, gastrointestinal, or lung disease Ø Denies ever being diagnosed with arthritis or osteoporosis Ø Reports her mother suffered from aching joints and was “bent over” due to severe scoliosis Ø Currently taking no medications or supplements Ø Has never taken hormone replacement therapy Ø Denies any drug allergies Ø States she prefers not to take medications because she is “sensitive". Question 3: Are there any important things to ask her about her life-style and social history? LIFE-STYLE AND SOCIAL HISTORY: Ø Patient does not exercise regularly. Has a treadmill that she used to walk of 20 minutes each morning. States that she quit walking on treadmill 6 months ago due to aching and “not any fun” Ø Activity primarily centers on gardening in summer and is very limited in winter months. Ø Lives with her husband on a large farm several miles from nearest town; rarely drives Ø Diet is well balanced, except it is high in sugar and sweet foods; poor dairy intake Ø Nonsmoker Ø Drinks one or two mixed drinks per week. Question 4: Based on history alone, what is the differential diagnosis of this patient’s musculoskeletal complaints? PHYSICAL EXAMINATION: Ø Alert, oriented, moderately overweight white female in no distress Ø T=37 C orally; HR=76 and regular; RR=14 and unlabored; BP 144/78, right arm (sitting) HEENT, Skin, Neck Ø PERRL, fundi clear without vascular changes Ø Pharynx pink, clear Ø Skin no rashes or ecchmoses Ø Not thyromegaly, adenopathy, or carotid bruits Ø Drinks 4 to 5 caffeinated beverages a day Lungs, cardiac Ø Lungs CTA, percussion Ø Good excursion Ø S¹, S² without murmur, rubs, or gallops Abdomen Ø Abdomen soft, round; no tenderness or organomegaly Ø Hemoccult result is negative Neurologic Ø Cranial nerves II-XII intact, sensory examination normal and symmetric Ø strengths 5/5 in bilateral upper and lower extremities Ø gait slow, stiff Ø cerebral function intact Musculoskeletal Ø Full ROM at shoulders and elbows Ø hands have decreased range of motion; Heberden and Bouchard nodules present in bilateral hand examination Ø Back has decreased flexion and extension, moderate scoliosis. Right shoulder slightly lower than left. No kyphosis or lordosis. Ø Hips have decreased ROM with internal/external rotation. Ø Knees enlarged with decreased flexion/extension and crepitation present bilaterally; right greater than left. Ø No joint heat, tenderness, or erythema present. Question 5: What are the pertinent positive and negative findings on physical exam? Question 6: What laboratory studies are indicated? LABORATORY AND RADIOGRAPHIC RESULTS Ø Chemistries including BUN, Cr, phosphate, and calcium normal Ø CBC normal and thyroid function tests are normal Ø Radiograph of right and left knees reveals joint space narrowing, subchondral sclerosis, and bone cysts Ø Radiograph of lumbosacral spine reveals joint space narrowing and osteoophyte formation that is the worst at L3-L4. No compression fracture. Ø No radiographic evidence of osteoporosis. Question 7: What is the diagnosis? Question 8: How should the patient be managed? CASE STUDY 4: Osteoarthritis INITIAL HISTORY: Ø 80 year old female complains of long - standing history of pain in bilateral hips, knees, and hands Ø Difficulty walking and getting up from sitting or kneeling position due to discomfort and “stiffness” Ø Reports low back pain for several years Ø Only history of fracture of right arm as a child at approximately age 9 Question 1: What other questions about her symptoms would you like to ask this patient? ADDITIONAL HISTORY >Pain in hips and knees have existed for many years, gradually getting worse. >Here today at encouragement of daughter and husband; states, I couldn’t get up when Iwas i n the flower garden. I had to crawl into the house.” >Reports joints on right side of body are most painful and troublesome >Reports weight gain of 10 pounds over past 4 months, which she attributes to decreased activity >Joints are most painful during rainy weather, in the morning, or after sitting or kneeling for a long time. Reports that joints loosen up aft er activity. >Farmer’s wife, active in flower and vegetable gardening, long history of horseback riding. >Reports being “thrown” 15 years ago and landing on her right hip. No known associated fracture; hasn’t ridden since. >Denies redness, swelling, or heat at the joint. >Reports low back pain which she has had for many years without recent exacerbation >Denies numbness, tingling, weakness, or shooting pain in her legs >States on rare occasions takes aspirin 325 mg for pain once or twice per we ek Question 2: What questions would you like to ask to ask her about her medical history? MEDICAL HISTORY: Ø Surgical history: Cholecystectomy Ø Medical history: Has given birth to 9 healthy children from 9 pregnancies Ø Seasonal affective disorderr Ø She denies history of cardiac, renal, endocrine, gastrointestinal, or lung disease Ø Denies ever being diagnosed with arthritis or osteoporosis CASE STUDY 4: Osteoarthritis INITIAL HISTORY: Ø 80 year old female complains of long-standing history of pain in bilateral hips, knees, and hands Ø Difficulty walking and getting up from sitting or kneeling position due to discomfort and “stiffness” Ø Reports low back pain for several years Ø Only history of fracture of right arm as a child at approximately age 9 Question 1: What other questions about her symptoms would you like to ask this patient? ADDITIONAL HISTORY >Pain in hips and knees have existed for many years, gradually getting worse. >Here today at encouragement of daughter and husband; states, I couldn’t get up when Iwas i n the flower garden. I had to crawl into the house.” >Reports joints on right side of body are most painful and troublesome >Reports weight gain of 10 pounds over past 4 months, which she attributes to decreased activity >Joints are most painful during rainy weather, in the morning, or after sitting or kneeling for a long time. Reports that joints loosen up after activity. >Farmer’s wife, active in flower and vegetable gardening, long history of horseback riding. >Reports being “thrown” 15 years ago and landing on her right hip. No known associated fracture; hasn’t ridden since. >Denies redness, swelling, or heat at the joint. >Reports low back pain which she has had for many years without recent exacerbation >Denies numbness, tingling, weakness, or shooting pain in her legs >States on rare occasions takes aspirin 325 mg for pain once or twice per week Question 2: What questions would you like to ask to ask her about her medical history? MEDICAL HISTORY: Ø Surgical history: Cholecystectomy Ø Medical history: Has given birth to 9 healthy children from 9 pregnancies Ø Seasonal affective disorderr Ø She denies history of cardiac, renal, endocrine, gastrointestinal, or lung disease Ø Denies ever being diagnosed with arthritis or osteoporosis

Medical Case Study

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