OsteoarthritisCase Study 78by Erica Ducker

Chief Complaints

-Trouble moving and going places-Joint pain, most severe in knees and in lower back.

History of Present Illness

-71 year old, overweight woman. -Complaining of long history or bilateral knee discomfort.-Discomfort in left knee greater than in the right knee. -Had lower back pain for many years, but recently has become worse. -Has difficulty using the stairs at home. -Rheumatologist tried a variety of nonsteroidal anti-inflammatory drugs to help with pain control, but they only gave her mild relief and caused significant intolerable stomach discomfort. -Pain alleviated with oxycodone. -Knees got significantly more painful after she gained 20 lbs in a span of 9 months.

Past Medical History

-At age 23, left knee injury in a motor vehicle accident, no surgery required.-Broken hip at age 60 by falling on icy sidewalk. Hip healed well, no significant symptoms suggest no hip involvement in present complaints.-14 year history of osteoarthritis, 10 year history of hypertension, 4 year history of hypercholesterolemia, 4 year history of diabetes mellitus type 2, -hospitalized for diverticulitis incident 2 years ago. -Only surgery was hysterectomy without oophorectomy 21 years ago. Menopause at age 49, never has taken hormones.

Family History

-Father died of acute myocardial infarction at age 53-Mother died of breast cancer at age 80

-Brother age 68, hypertension-Sister age 74, severe allergies, two mitral valve replacements for rheumatic heart disease-Sister age 72, osteoarthritis

-Positive history of osteoporosis in mother and maternal grandmother

Social History

-Lives with her 72 year old sister in 3-story townhouse near the beach.-Exercises regularly in the pool, sometimes ocean. Can no longer walk long distances daily as she did in the past.-Well balanced diet with plenty of fresh fruit, vegetables, whole grains, dairy, admits to eating too many sweets.-Has Medicare but no other health insurance.-Does not smoke-Drinks 1-2 cocktails or glasses of white wine with dinner.-Hobbies: quilting, baking, teaching piano to children.

Review of Systems-Mild pain in right shoulder with lifting and carrying.-Lower back pain with occasional shooting pains radiating to back of thigh.-Deep aching pain in the pretibial area bilaterally and extending distally to the ankles and toes.-Denies swollen, red, hot joints, but notes “hard lumps” at the margins of the interphalangeal joints.-Denies numbness and weakness in legs, denies discomfort in wrists and elbows.-Negative for headaches, neck stiffness, shortness of breath, chest pains, urinary frequency or dysuria, constipation, diarrhea, nausea, loss of appetite, or significant changes in the appearance of urine or stools.-Finger-stick blood glucose levels are usually around 180 mg/dL-Occasional polyuria but no changes in vision

MedicationsZolpidem 10 mg po Q HS PRNAtorvastatin 20 mg po Q HSAtenolol 25 mg po QDLisinopril 40 mg po QDMetformin 250 mg po QDGlipizide 2.5 mg po QDAcetaminophen 1000 mg po TIDHigh-potency multivitamin supplement with calcium, iron, and zinc po QDCalcium 600 mg with Vitamin D 125 IU supplement po BID with meals

No known allergies

Physical Exam

GeneralAlert, well developed and well nourished, overweight caucasian female who appears slightly anxious but otherwise in no acute or apparent distress.

Vital SignsBlood pressure, sitting, left arm 155/88Pulse 72 and regularRespiratory rate 15 and unlaboredTemperature 98.8 Degrees FHeight 5’3”Weight 164 lbs

Physical Exam

SkinWarm, dry, normal turgor, no petechiae, ecchymoses, or rash

Head, Eyes, Ears, Nose, ThroatNormocephalic/AtraumaticPupils equal, round, and reactive to light and accommodationFunduscopic exam reveals sharp discs with no vascular abnormalities or papilledemaNegative scleral icterusTympanic membranes intactMucous membranes moistNegative lateral deviation of tongue, pharyngeal edema, or erythema

Physical ExamNeck/Lymph nodesNeck supple, negative for thyromegaly, adenopathy, masses, jugular venous distension, or carotid bruits

Chest/LungsGood chest excursion, Lungs clear to auscultation and pulse

HeartNormal S1 and S2, point of maximal impulse normal at 5th intercostal space, regular rate and rhythmn, No murmur/rub/gallop

AbdomenSoft and non-tender without guarding, positive for bowel sounds, negative organomegaly, bruits, and masses

BreastsSymmetric, no apparent masses, discharge, discoloration, or dimpling

Physical ExamGenitalia/RectumNormal female genitalia, positive for mild vaginal atrophy, normal anal sphincter tone, stool heme-negative.

Musculoskeletal/ExtremitiesBack with decreased flexion and extensionBack pain radiating to right buttock with straight right leg raising >60 degreesFull range of motion at left shoulder, elbows, and anklesMild left hip discomfort with flexion >90 degrees and with internal and external rotation >45 degreesHips not tender to palpationBilateral knee crepitus and enlargement but more pronounced in left kneeSlight decrease in range of motion and both Bouchard and Heberden nodes observed bilaterally during hand examination; no tenderness in finger jointsFeet without breakdown, ulcers, erythema, or edema

Laboratory Blood Test ResultsNa 137 meq/LK 4.4 meq/LCl 108 meq/LHCO3 23 meq/LBUN 7 mg/dLCr 0.6 mg/dLGlu, fasting 241 mg/dLHb 13.5 g/dLHct 39.1%MCV 87 flMCH 27.7 pgMCHC 31.8 g/dL

WBC 5.2x10^3/mm^3

Plt 239 x 10^3/mm^3AST 31 IU/LALT 19 IU/LBilirubin, total 0.6 mg/dLAlk phos 97 IU/LProtein, total 7.9 g/dLAlb 4.2 g/dLCholesterol 248 mg/dLHbA1c 7.5%Ca 8.7 mg/dLPO4 2.9 mg/dLMg 1.9 mg/dLESR 14 mm/hrTSH 1.9 uU/mL

UrinalysisAppearance: Pale yellow, clearSpecific gravity 1.017pH 6.3WBC 0/HPFRBC 0/HPFLeukocyte esterase: negativeNitrites: negativeBacteria: negativeProtein: negativeKetones: negative

X-Rays

Lumbosacral spineAdvanced degenerative changes with disk space narrowing and osteophyte formation at L3-4 and L4-5.

X-Rays

-No evidence of compression fracture left hip-Mild to moderate degenerative changes with mild osteophytosis of femoral head-Slight narrowing in joint space, right and left knees-Moderate degenerative changes with joint space narrowing, subchondral sclerosis, and bone cysts-No radiographic evidence of osteoporosis or joint effusions, right shoulder-Mild degenerative changes with bone spurs at head of humerus-Slight narrowing in joint space

Case Questions

What is crepitus?What are four risk factors of Osteoarthritis?What is the primary cause for limited range of motion in osteoarthritis?What blood test result distinguishes between gouty arthritis and osteoarthritis?

Thank you for your attention!