Clinical findings of a patient with osteoarthritis

Create a pathophysiology flow chart or diagram showing the clinical findings of a patient with osteoarthritis. Kindly refer to the case study attached below.

 

P.S. Pathophysiology should be in a flow chart or diagram form with explanation and kindly cite the reference

 

 

Reference: http://repository.stikesrspadgs.ac.id/71/1/100%20Case%20Studies%20in%20Pathophysiology-532hlm%20%28warna%20hanya%20cover%29.pdf

 

Case Study

Patient’s Chief Complaints

“I’m really having trouble getting around. My joints have been killing me. Knees and lower back are the worst. Other doctors won’t give me what I need to feel better.”

History of Present Illness

G.J. is a 71 yrs. old overweight woman who presents to the Family Practice Clinic for the first time complaining of a long history of bilateral knee discomfort that becomes worse when it rains and usually feels better when the weather is warm and dry. “My arthritis hasn’t improved a bit this summer though,” she states. Discomfort in the left knee is greater than in the right knee. She has also suffered from low back pain for many years, but recently it has become worse. She is having difficulty using the stairs in her home.

The patient had recently visited a rheumatologist who tried a variety of NSAIDs to help her with pain control. The medications gave her mild relief but also caused significant and intolerable stomach discomfort. Her pain was alleviated with oxycodone. However, when she showed increasing tolerance and began insisting on higher doses of the medication, the physician told her that she may need surgery and that he could not prescribe more oxycodone for her. She is now seeking medical care at the Family Practice Clinic.

Her knees started to get significantly more painful after she gained 20 pounds during the past nine months. Her joints are most stiff when she has been sitting or lying for some time and they tend to “loosen up” with activity. The patient has always been worried about osteoporosis because several family members have been diagnosed with the disease. However, no clinical manifestations of osteoporosis have developed.

Past Medical History

At age 23, the patient suffered a left knee injury in an MVA that did not require surgery. She also suffered a broken left hip 11 years ago when she fell on an icy sidewalk while visiting her sister in Michigan. Her hip seemed to have healed well as she has no significant symptoms that suggest hip joint involvement.

The patient has a 14-year history of OA, a 10-year history of HTN, a 4-year history of hypercholesterolemia, and a 4-year history of DM type 2. She also was hospitalized for an episode of diverticulitis two years ago. Her only surgery was a hysterectomy without oophorectomy 21 years ago. Menopause occurred at age 49, but she has never taken hormones.

Family History

• Father died from AMI at age 53

• Mother died from breast CA at age 80

•  Patient has one brother, age 68, with HTN; one sister, age 74, who has severe allergies and has had two mitral valve replacements for rheumatic heart disease; and one sister, age 72, who also has OA

• Positive history of osteoporosis in mother and maternal grandmother

 

Social History

• Lives with her 72 yrs. old sister in a 3-story townhouse near the beach

• Exercises regularly in the pool and, sometimes, in the ocean, but can no longer walk long distances daily as she has done in the past

• Has a well-balanced diet with plenty of fresh fruits and vegetables, whole grains, and dairy products, but admits to eating “too many sweets”

• Has Medicare but no other health insurance

• Does not smoke and drinks 1-2 cocktails or glasses of white wine every evening with her meal

• Hobbies include quilting, baking, and teaching piano to children

Review of Systems

• Mild pain in right shoulder with lifting, carrying

• Low 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

• Patient denies any swollen, red, or hot joints, but notes “hard lumps” at the margins of the interphalangeal joints

• Patient denies numbness or weakness in her legs

• Patient denies pain or discomfort in her wrists and elbows

• Negative for headaches, neck stiffness, SOB, chest pains, urinary frequency or dysuria, constipation, diarrhea, nausea, loss of appetite, or significant changes in the appearance of her urine or stools

• Finger-stick blood glucose levels are usually around 180 mg/dL

• Occasional polyuria but no changes in vision

Medications

• Zolpidem 10 mg po Q HS PRN

• Atorvastatin 20 mg po Q HS

• Atenolol 25 mg po QD

• Lisinopril 40 mg po QD

• Metformin 250 mg po QD

• Glipizide 2.5 mg po QD

• Acetaminophen 1000 mg po TID

• High-potency multivitamin supplement with calcium, iron, and zinc po QD

• Calcium 600 mg with Vitamin D 125 IU supplement po BID with meals

Allergies

No known drug allergies

Physical Examination and Laboratory Tests

General

Alert, WDWN, overweight Caucasian female who appears slightly anxious but otherwise in NAD

 

Vital Signs

 

Patient Case Vital Signs
BP sitting, left arm            155/88	RR	15 and unlabored	HT	5 ft-3 in
P          72 and regular	T	98.8°F	WT	164 lbs

 

 

Skin	Warm and dry with normal turgor No petechiae, ecchymoses, or rash
Head, Eyes, Ears, Nose and Throat	NC/AT PERRLA
Neck and Lymph Nodes	Neck supple (-) evidence of thyromegaly, adenopathy, masses, JVD, or carotid bruits
Chest	Good chest excursion Lungs CTA & P
Breast	Symmetric No apparent masses, discharge, discoloration, or dimpling
Abdomen	Soft and non-tender without guarding (+) BS (-) organomegaly, bruits, and masses
Genitalia	Normal female genitalia (+) mild vaginal atrophy Normal anal sphincter tone Stool heme-negative
Musculoskeletal/Extremities	Back with decreased flexion and extension Back pain radiating to right buttock with straight right leg raising >60° Full ROM at left shoulder, elbows, and ankles Mild left hip discomfort with flexion >90° and with internal and external rotation >45° Hips not tender to palpation Bilateral knee crepitus and enlargement but more pronounced in left knee Slight decrease in ROM and both Bouchard and Heberden nodes observed bilaterally during hand examination; no tenderness in finger joints No redness, heat, or swelling in joints Feet without breakdown, ulcers, erythema, or edema
Neurologic	Oriented X 3 Cranial nerves intact Sensory exam normal and symmetric to pinprick and vibration DTRs 2+ and equal bilaterally except for 1+ Achilles reflexes bilaterally Strength 5/5 in both upper extremities; 4/5 in lower extremities Gait slow but without specific deficits Coordination WNL No focal deficits (-) Babinski bilaterally

 

 

 

 

Laboratory Blood Test Results

 

 

Patient Case Table 78.2 Laboratory BloodTest Results
Na	137 meq/L	MCV	87 fL	Protein, total	7.9 g/dL
K	4.4 meq/L	MCH	27.7 pg	Alb	4.2 g/dL
Cl	108 meq/L	MCHC	31.8 g/dL	Cholesterol	248 mg/dL
HCO3	23 meq/L	WBC	5.2 X 103/mm3	HbA1c	7.5%
BUN	7 mg/dL	Plt	239 X 103/mm3	Ca	8.7 mg/dL
Cr	0.6 mg/dL	AST	31 IU/L	PO4	2.9 mg/dL
Glu, fasting	241 mg/dL	ALT	19 IU/L	Mg	1.9 mg/dL
Hb	13.5 g/dL	Bilirubin, total	0.6 mg/dL	ESR	14 mm/hr
Hct	39.1%	Alk phos	97 IU/L	TSH	1.9 µU/mL

 

 

Urinalysis

 

 

Patient Case Table 78.3 Urinalysis
Appearance	Pale yellow, clear	Leukocyte esterase	Negative
Specific gravity	1.017	Nitrites	Negative
pH	6.3	Bacteria	Negative
WBC	0/HPF	Protein	Negative
RBC	0/HPF	Ketones	Negative

 

X-Rays

 

Lumbosacral spine

• Advanced degenerative changes with disk space narrowing and osteophyte formation at L3-4 and L4-5

• 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