CASE STUDY 4: Osteoarthritis

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
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?

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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?