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.”

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  >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”. CASE STUDY 4: Osteoarthritis

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

CASE STUDY 4: Osteoarthritis