CASE STUDY 4 OsteoarthritisINITIAL HISTORYØ 80 year old f

CASE STUDY 4: OsteoarthritisINITIAL HISTORY:Ø 80 year old female complains of long-standing history of pain in bilateral hips, knees, and handsØ Difficulty walking and getting up from sitting or kneeling position due to discomfort and “stiffness”Ø Reports low back pain for several yearsØ 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 weekQuestion 2:  What questions would you like to ask to ask her about her medical history?MEDICAL HISTORY:Ø Surgical history: CholecystectomyØ Medical history: Has given birth to 9 healthy children from 9 pregnanciesØ Seasonal affective disorderrØ She denies history of cardiac, renal, endocrine, gastrointestinal, or lung diseaseØ Denies ever being diagnosed with arthritis or osteoporosisØ Reports her mother suffered from aching joints and was “bent over” due to severe scoliosisØ Currently taking no medications or supplementsØ Has never taken hormone replacement therapyØ Denies any drug allergiesØ 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 drivesØ Diet is well balanced, except it is high in sugar and sweet foods; poor dairy intakeØ NonsmokerØ 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 distressØ T=37 C orally; HR=76 and regular; RR=14 and unlabored; BP 144/78, right arm (sitting)HEENT, Skin, NeckØ PERRL, fundi clear without vascular changesØ Pharynx pink, clearØ Skin no rashes or ecchmosesØ Not thyromegaly, adenopathy, or carotid bruitsØ Drinks 4 to 5 caffeinated beverages a dayLungs, cardiacØ Lungs CTA, percussionØ Good excursionØ S¹, S² without murmur, rubs, or gallopsAbdomenØ Abdomen soft, round; no tenderness or organomegalyØ Hemoccult result is negativeNeurologicØ Cranial nerves II-XII intact, sensory examination normal and symmetricØ strengths 5/5 in bilateral upper and lower extremitiesØ gait slow, stiffØ cerebral function intactMusculoskeletalØ Full ROM at shoulders and elbowsØ hands have decreased range of motion; Heberden and Bouchard nodules present in bilateral hand examinationØ 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 RESULTSØ Chemistries including BUN, Cr, phosphate, and calcium normalØ CBC normal and thyroid function tests are normalØ Radiograph of right and left knees reveals joint space narrowing, subchondral sclerosis, and bone cystsØ 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?

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