CASE STUDY: Osteoarthritis

INITIAL HISTORY:

- 80 year old female complains of long-standing history of pain in bilateral hips, knees, and hands
- Difficulty walking and getting up from sitting or kneeling position due to discomfort and "stiffness"
- Reports low back pain for several years
- 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:

- Surgical history: Cholecystectomy
- Medical history: Has given birth to 9 healthy children from 9 pregnancies
- Seasonal affective disorderr
- She denies history of cardiac, renal, endocrine, gastrointestinal, or lung disease
- Denies ever being diagnosed with arthritis or osteoporosis
- Reports her mother suffered from aching joints and was "bent over" due to severe scoliosis
- Currently taking no medications or supplements
- Has never taken hormone replacement therapy
- Denies any drug allergies
- 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:

- 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"
- Activity primarily centers on gardening in summer and is very limited in winter months.
- Lives with her husband on a large farm several miles from nearest town; rarely drives
- Diet is well balanced, except it is high in sugar and sweet foods; poor dairy intake
- Nonsmoker

- 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:

- Alert, oriented, moderately overweight white female in no distress
- T=37 C orally; HR=76 and regular; RR=14 and unlabored; BP 144/78, right arm (sitting) HEENT, Skin, Neck
- PERRL, fundi clear without vascular changes
- Pharynx pink, clear
- Skin no rashes or ecchmoses
- Not thyromegaly, adenopathy, or carotid bruits
- Drinks 4 to 5 caffeinated beverages a day

Lungs, cardiac

- Lungs CTA, percussion
- Good excursion
- S¹, S² without murmur, rubs, or gallops

Abdomen

- Abdomen soft, round; no tenderness or organomegaly
- Hemoccult result is negative

Neurologic

- Cranial nerves II-XII intact, sensory examination normal and symmetric
- strengths 5/5 in bilateral upper and lower extremities
- gait slow, stiff
- cerebral function intact

Musculoskeletal

- Full ROM at shoulders and elbows
- hands have decreased range of motion; Heberden and Bouchard nodules present in bilateral hand examination
- Back has decreased flexion and extension, moderate scoliosis. Right shoulder slightly lower than left. No kyphosis or lordosis.
- Hips have decreased ROM with internal/external rotation.
- Knees enlarged with decreased flexion/extension and crepitation present bilaterally; right greater than left.
- 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

- Chemistries including BUN, Cr, phosphate, and calcium normal
- CBC normal and thyroid function tests are normal
- Radiograph of right and left knees reveals joint space narrowing, subchondral sclerosis, and bone cysts
- Radiograph of lumbosacral spine reveals joint space narrowing and osteoophyte formation that is the worst at L3-L4. No compression fracture.
- No radiographic evidence of osteoporosis.

Question 7: What is the diagnosis?

Question 8: How should the patient be managed?