B. is a 71 yo overweight male who presents to your clinic for the first time complaining of months to years of bilateral knee pain
Case Study #1 Osteoarthritis
Patients Chief Complaint:
I’m having difficulty walking, my joints have been killing me for the past 3 months. My knees and lower back hurts.
History of Present Illness:
B. is a 71 yo overweight male who presents to your clinic for the first time complaining of months to years of bilateral knee pain that becomes worse with rain and feels better when the weather is warm and dry. He is now concerned because the arthritis symptoms have not an improved this summer. The pain in the right knee is greater than the left knee. He is also concerned about back pain he has had for several years that has recently become worse. He has difficulty using the stairs in his home.
The patient has recently visited an orthopedic provider who treated him with a variety of NSAIDs to help control the pain. The medication did provide mild relief, but also caused a lot of G.I. upset, nausea and stomach pain. The pain has previously been relieved with oxycodone, but he did require increasing doses of this medication. The provider who was treating him with the oxycodone, told him he may need surgery, and that they could not prescribe any further doses of oxycodone. He is now seeking medical care at your practice.
The knee pain started to get significantly worse after he gained 30 pounds over the past eight months. He complains of joint stiffness that is worse when he has been sitting or laying for a period of time, and the joints seem to loosen up with activity.
Past Medical History:
Previous left knee injury, secondary to MVA without surgical intervention.
Left hip fracture 11 years ago with ORIF.
Osteoarthritis
Hypertension
Hyperlipidemia
Diabetes
Current Medications:
Ambien 10 mg PO QHS PRN.
Atorvastatin 20 mg PO QHS
Atenolol 25 mg PO daily
Lisinopril 40 mg 40 daily
Metformin 500 mg b.i.d.
Glipizide 2.5mg po daily
Ibuprofen 400 mg PO Q6hr PRN
Tylenol 1000 mg PO Q8hr PRN
Allergies:
NKDA
Family History:
Father died from MI age of 53.
Mother died from breast cancer age of 80
Brother age 68 with hypertension
Sister age 74 history of rheumatic heart disease with valve replacement and hx of OA
Social History:
Married lives with his wife in a two-story townhouse. Exercises by walking dog daily, but short distances down the block due to pain. Diet is high in processed foods but does try to incorporate fruits and vegetables. Eats a lot of sweets.
Non-smoker.
Alcohol use socially
Denies drug use.
Review of Systems:
General: Denies fever, sweats or chills. Denies weakness, fatigue. Endorses weight increase.
Skin: denies rashes, lumps, sores, itching, dryness, changes in color, changes in hair or nails, changes in sizes or color of moles
HEENT: No use of glasses. Denies headache, head injury, dizziness, lightheadedness. Denies use of contact lenses, denies eye pain, redness, excessive tearing, double or blurred vision, spots, specks or flashing lights. Endorses good hearing. Denies tinnitus, vertigo, frequent ear infections. Denies frequent colds, nasal stuffiness, discharge or itching. Denies hay fever, nose bleeds. Endorses good dentition. Denies bleeding gums. Denies sore tongue, dry mouth, frequent sore throat or hoarseness
Neck: denies swollen glands, goiter, lumps, pain or stiffness
Breast: denies lumps, pain, discomfort or nipple discharge
Respiratory: denies cough, sputum, shortness of breath, wheezing, pleuritic pain
CVS: Endorses high blood pressure, denies heart murmurs, chest pain, shortness of breath, Orthopnea
GI: Endorses diarrhea. denies trouble swallowing, heartburn, changes in appetite. Denies nausea. Denies changes in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation. Denies abdominal pain
Peripheral Vascular: Denies claudication, leg cramps, varicose veins. Denies history of DVT. Denies swelling in calves, legs or feet,
Urinary: denies increase frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria. Denies frequent urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence
Msk: Endorses right shoulder pain with lifting, carrying. Endorses low back pain with occasional radiculopathy. Endorses bilateral knee pain right greater than left. Denies joint swelling. No wrist or elbow pain.
Psych: Denies nervousness, tension, depression, memory change, suicidal ideation, plans or attempts.
Neuro: Denies headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements, denies seizures.
Hematology: denies anemia, easy bruising or bleeding
Endocrine: Denies heat/cold intolerance, excessive sweating, excessive thirst
Psych: Denies changes in mood, attention, or speech; denies changes in orientation, memory, insight or judgement.
Physical Exam:
Vital Signs: 37.2, 72, 15 unlabored, 155/88, 99% RA
Ht 5 ft 10 inches Wt 260 lbs BMI 37.3
General: Alert, oriented, ambulatory, appears stated age.
Skin: warm, dry, normal cheddar, no petechiae, no ecchymoses, no rash.
HEENT: Head: NCAT; Eyes: PERRLA, EOMI, no scleral icterus; Ears: external ear, no tragus tenderness, TM gray, intact; Nose: mucous membranes are moist, no polyps. Mouth: mucous membranes, moist, no pharyngeal edema or edema
Neck/Lymph Nodes: Neck supple, trachea is midline, no masses. No lymphadenopathy.
Heart: Regular, normal S1 & S2
Lungs: Respirations are regular, easy, lungs are clear bilaterally, no wheezes.
Abdomen: No rashes or lesions noted, bowel sounds are positive, no tenderness, no rebound or guarding
Musculoskeletal/Extremities: there is no focal, midline, cervical, thoracic, or lumbar spine tenderness. There is bilateral paraspinal tenderness of the lumbar spine in the area of L3, extending towards the sacrum, which is not focal. Worsening pain with forward flexion of the spine. Right lower extremity straight leg raise is positive. Upper extremities with full, non-painful range of motion of the shoulders, elbows & wrist.
Lower extremities: Right hip pain with flexion to 90°, as well as internal and external rotation of the hip. Right knee with diffuse tenderness anteriorly without erythema or edema. There is crepitus noted with right knee range of motion. Right ankle is normal. Left hip without pain. Left knee does have mild tenderness with flexion as well as extension of the knee. No joint laxity is noted.
Neuro: A&O X’s3, CN II-XII intact, sensation is intact, +2 patellar reflexes bilaterally. Strength is 5/5 upper extremities and 4/5 of both lower extremities.
Based on the case information you were given, and this patients diagnosis of osteoarthritis answer the following eight (8) questions:
- A brief introduction of the disease process and the significance of the problem across the lifespan.
- Pathophysiology of the disease process.
- History and physical findings related to the disease.
- Discuss crepitus as it relates to osteoarthritis.
- Incidence and prevalence of disease
- Identify four risk factors that have predisposed this patient to osteoarthritis.
- Role of APRN and the use of pharmacological and non-pharmacological treatments specific to patient’s condition.
- Prognosis and long-term care considerations.
Review current evidence-based treatment guidelines related to research findings specific to the disease process. If you choose to use a resource in addition to your text you must use a peer-reviewed source that is current and published within the past 5 years. Information from this source must be cited per APA guidelines.
For each answer please use the topic of the question as a heading prior to answering, so that it is clear what question you are answering. Your paper should have a total of eight (8) headings as there are eight (8) questions noted above.
TEXT BOOK : –
Norris, T. (2019). Porth’s Pathophysiology: Concepts of Altered Health States. 10th Ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. ISBN: 978-1-975101-15-2
Expert Answer and Explanation
Osteoarthritis Case Analysis
The Disease Process and Its Significance Across the Lifespan
Osteoarthritis is a degenerative joint condition linked to the degradation of joint structures (Mahmoudian et al., 2021). It is the most common form of arthritis and occurs more often in older adults. Usually, osteoarthritis patients report joint pain along with a few seconds of stiffness in the morning or after periods of inactivity. This results from the cartilage degeneration that cushions the ends of bones (Norris, 2019).
Although osteoarthritis can affect any joint, it is most commonly found in the hands, spine, knees, and hips. The symptoms of the disease occur slowly and worsen as time goes on. One of the main symptoms of the disease is pain in the joints because of joint injury during or after movement. Another symptom is joint stiffness after being inactive for a long time or awakened. Other symptoms include grating sensation, swelling of the affected joint, loss of flexibility, bone spurs, and tenderness (Mahmoudian et al., 2021).
The disease negatively impacts the life of the affected individual. People with the disease often have limited movement and lose independence to engage in activities such as bathing, walking, and going to work (Mahmoudian et al., 2021). The pain caused by the disease is also severe and can negatively impact the quality of life of a patient. The patient’s financial status can be impacted negatively, especially in the case of severe OA that needs surgery.
Pathophysiology of Osteoarthritis
The pathophysiology of osteoarthritis is multifaceted and intertwined. Three primary processes characterize the pathophysiology of OA: joint inflammation, structural degradation, and mechanical wear and tear (Khlopas et al., 2019). Though aging and overuse are assumed to be the primary reasons for this process, higher levels of different cytokines and chemokines in the synovium of the affected joints also reveal a sign of an inflammatory course (Khlopas et al., 2019).
Matrix metalloproteinases are triggered, and the cartilage extracellular matrix is broken down. According to Khlopas et al. (2019), cartilage strain indirectly induces chondrocyte activation, proliferation and subsequently the synthesis of degrading enzymes. Chondrocytes later undergo apoptosis; this results in an overall decrease in cell numbers (Khlopas et al., 2019). The first anatomical stage of osteoarthritis is articular cartilage degradation, which comprises surface fibrillation, irregularity and isolated erosions.
Injury to the cartilage may stimulate chondrocyte division, and their offspring may hypertrophy into osteophytes or bone spurs (Khlopas et al., 2019). Subchondral bone sclerosis, as well as the formation of bone cysts at a later stage, can aggravate joint pain and stiffness (Khlopas et al., 2019). The advanced disease leads to episodic synovitis. Bony erosions are uncommon, but they occur in erosive OA.
History and Physical Findings Related to the Disease
A lot of history findings are related to OA in the case. One of the historical findings is that he has had problems walking in the past three months. Also, he has experienced joint pain for the last three months. Lower back and knee pain are also linked to OA. OA is also linked with the patient’s complaint of knee pain that has lasted many months to years.
Problems using stairs at his home also indicate OA (Mohammadinejad et al., 2020). Another historical finding is the use of a variety of NSAIDs to help the patient control pain in the joints and knee. The use of oxycodone in the past to relieve pain also indicates severe OA. Other history findings include joint stiffness that increases when he sits or sleeps for some time, a fracture in the left hip 11 years ago, and a previous knee injury.
Apart from historical findings, physical findings show that the patient has OA. One of the findings is that he feels pain when his right hip is raised to 90°. His right knee is tender to touch, mild tenderness in the left hip and pain in the spine that worsens when flexed forward. Reduced range of motion in the left need and decreased strength in the lower joints, crepitus present with the movement of the right knee, and muscles also indicate OA (Mohammadinejad et al., 2020).
Crepitus as it Relates to Osteoarthritis
A grating or crunching sound that accompanies the movement of a joint is known as crepitus. While joint crepitus is frequent in old age, not all cases indicate an underlying illness. On the other hand, joint crepitus typically indicates joint injury when it is accompanied by discomfort or swelling (Pazzinatto et al., 2019). Crepitus is frequently caused by arthritis, especially OA, particularly in the elderly. A structure, possibly a ligament or tendon, cracking over a joint could cause the sound, which could be muffled or loud enough for others to hear.
As with OA, crepitus is more frequently caused by the grinding of the two joint surfaces. It happens when the naked subchondral bones in the joint brush against or grind against one another (Pazzinatto et al.,2019).
A damaged cartilage piece may also rub against the joint’s surface, causing crepitus. Meniscus tears occur in the knees due to OA, and further deterioration may cause locking and sound. When the protecting articular cartilage is gone, the joint grinds like sandpaper, causing crepitus instead of gliding smoothly (Pazzinatto et al., 2019).
Incidence and Prevalence of Osteoarthritis
Osteoarthritis affected 528 million individuals globally in 2019, an increase of 113% from 1990 (World Health Organization, 2023). Sixty percent of those with osteoarthritis are women, and about 73% of those with the condition are older than 55. The knee is the most commonly affected joint (365 million cases), followed by the hip and the hand. Rehabilitation could be beneficial for 344 million people who suffer from mild to severe osteoarthritis (WHO, 2023).
Globally, osteoarthritis prevalence is predicted to rise because of aging populations, rising rates of obesity, and an increase in injuries. According to CDC estimates, 53.2 million persons in the US have arthritis in one form or another (Center for Disease Control, 2023). OA, which affects 32.5 million adults in the US, is the most prevalent type of arthritis, though there are thought to be more than 100 varieties.
Adults who reported no recreational physical activity had the highest prevalence of arthritis (30.9%) compared to those who fulfill the recommendation for physical activity (18.8%) or are inadequately active (27.0%) (CDC, 2023).
Identify four risk factors that have predisposed this patient to osteoarthritis.
One of the risk factors that has predisposed the patient to OA is obesity. He et al. (2020) noted that the risk of developing OA increases with weight gain. Obesity puts pressure on the joints, a scenario that can lead to joint injury and cause OA. The second risk factor is the patient’s age. At 71 years, the patient’s risk of developing OA is high (He et al., 2020). Age increases the risk for OA because older people have weaker bones, which can be injured easily, and this can lead to the development of OA.
The third risk factor is the previous injury. The patient reported that he had a hip fracture 11 years ago. He also mentioned that he suffered a knee injury. The two injuries increased the patient’s risk of developing OA (He et al., 2020). Lastly, the patient had a joint surgery, and this weakened his joint, increasing the risk of developing OA.
Role of APRN and pharmacological and non-pharmacological treatments specific to patient’s condition.
APRNs have various roles in this case. One of the roles is to comprehensive assess the patient by collecting data regarding his past medical history and current clinical manifestation to provide proper diagnosis. Another role is to provide patient education. The patient should be educated about OA and how it will impact his life in the long run. Patient education will ensure that the patient is conversant with his health status. APRN is also responsible for prescribing medications and ensuring that the patient takes the medications has prescribed.
The patient can be prescribed oral acetaminophen for treatment since it is effective in treating knee OA (Brophy & Fillingham, 2022). He can be prescribed acetaminophen 325 mg to 1 g orally every six hours (Brophy & Fillingham, 2022). If the pain persists, he can be asked to take it every four hours. Non-pharmacological treatment includes the development of a plan to help the patient lose weight. He can also engage in light exercises that do not put pressure on his knees (Brophy & Fillingham, 2022). Physical therapy and massage from professionals can also help him recover.
Prognosis and long-term care considerations.
OA is a chronic pain condition with no cure. As time goes on, the disease progresses and becomes worse. Treatments are used to reduce denegation but not to cure it (Brophy & Fillingham, 2022). Ultimately, the patient might undergo surgery to replace his hip or leg. The patient’s prognosis is not bad, considering that he has other medical problems, such as high blood pressure, diabetes, and obesity (Brophy & Fillingham, 2022). Medications are expected to slow the disease. However, it will become worse in the next 10 to 15 years.
Long-term care considerations include physical therapy, the use of mobility aids such as canes, using a wheelchair to reduce pressure on the knee, and surgery in the next eight to 10 years. The patient can also benefit from education on how to live with the condition (Brophy & Fillingham, 2022). He should also be enrolled in a weight loss program as a way of managing the condition in the long term.
Conclusion
The patient has OA. Some factors that increase the patient’s risk of developing OA include his weight, age, previous surgery, and past injury in the hip and knee. The patient should be prescribed painkillers such as acetaminophen to help reduce pain. However, treatment should focus on long-term management. He should be urged to engage in a weight loss program, take medications as prescribed, and prepare for surgery if the disease progresses.
References
Brophy, R. H., & Fillingham, Y. A. (2022). AAOS clinical practice guideline summary: management of osteoarthritis of the knee (nonarthroplasty). JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 30(9), e721-e729. https://journals.lww.com/jaaos/fulltext/2022/05010/aaos_clinical_practice_guideline_summary_.10.aspx
Center for Disease Control. (2023). National statistics. https://www.cdc.gov/arthritis/data_statistics/national-statistics.html
He, Y., Li, Z., Alexander, P. G., Ocasio-Nieves, B. D., Yocum, L., Lin, H., & Tuan, R. S. (2020). Pathogenesis of osteoarthritis: risk factors, regulatory pathways in chondrocytes, and experimental models. Biology, 9(8), 194. https://doi.org/10.3390/biology9080194
Khlopas, H., Khlopas, A., Samuel, L. T., Ohliger, E., Sultan, A. A., Chughtai, M., & Mont, M. A. (2019). Current concepts in osteoarthritis of the ankle: Review. Surgical Technology International, 35, 280–294. https://pubmed.ncbi.nlm.nih.gov/31237341/
Mahmoudian, A., Lohmander, L. S., Mobasheri, A., Englund, M., & Luyten, F. P. (2021). Early-stage symptomatic osteoarthritis of the knee—time for action. Nature Reviews Rheumatology, 17(10), 621-632. https://doi.org/10.1038/s41584-021-00673-4
Mohammadinejad, R., Ashrafizadeh, M., Pardakhty, A., Uzieliene, I., Denkovskij, J., Bernotiene, E., Janssen, L., Lorite, G. S., Saarakkala, S., & Mobasheri, A. (2020). Nanotechnological strategies for osteoarthritis diagnosis, monitoring, clinical management, and regenerative medicine: Recent advances and future opportunities. Current Rheumatology Reports, 22(4), 12. https://doi.org/10.1007/s11926-020-0884-z
Norris, T. (2019). Porth’s Pathophysiology: Concepts of Altered Health States. 10th Ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. ISBN: 978-1-975101-15-2
Pazzinatto, M. F., de Oliveira Silva, D., Faria, N. C., Simic, M., Ferreira, P. H., Azevedo, F. M., & Pappas, E. (2019). What are the clinical implications of knee crepitus to individuals with knee osteoarthritis? An observational study with data from the Osteoarthritis Initiative. Brazilian Journal Of Physical Therapy, 23(6), 491–496. https://doi.org/10.1016/j.bjpt.2018.11.001
World Health Organization. (2023). Osteoarthritis. Key facts. https://www.who.int/news-room/fact-sheets/detail/osteoarthritis
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