Aquifer week 5_ case 11
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Dec 6, 2023
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Family Medicine 11: 74-year-old female with knee pain
United States University
FNP591: Common Illnesses Across the Lifespan
Dr. Ashley Roussell, DNP, MSN-FNP, BSN
October 2, 2023
2
Aquifer Week 5 Case 11: Musculoskeletal
Ms. Roman, a 74-year-old woman, complained of right knee discomfort, rated 6/10, and
was worsening during the previous two weeks. She denies injury and trauma and has only
experienced aching and grinding pain. The right knee has a decreased range of motion and creaks
when moved. As she has a history of GERD, she claims that OCT Bengay ointment helped ease
her right knee pain. Age, the patient's history of chronic joint pain, the clinical examination, and
radiographic imaging all contribute to the diagnosis and help rule out other differentials (Cash et
al., 2021).
1.
Differential Diagnosis
1)
Anterior cruciate ligament sprain rational and supporting evidence
a.
History:
●
An injury mechanism that involves
deceleration/acceleration in combination with a knee valgus
load.
●
Experiencing or hearing a "pop" when injured.
●
Hemarthrosis within 2 hours of injury.
b.
Clinical examination:
●
The Lachman test has the highest reported sensitivity and
specificity of any clinical diagnostic test, at 85% and 94%,
respectively.
●
The anterior drawer test: high sensitivity and specificity for
chronic ACL sprain.
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●
Medial and lateral knee pain was present during the valgus
and varus stress tests, with pain/instability at 30 degrees of
flexion (Filbay & Grindem, 2019).
c.
Physical history and clinical exam findings for the differential
diagnosis.
Since there is no sign of trauma, she exercises excessively
given her history of injury, there is no discomfort, and
neither the varus nor valgus stress tests show laxity; they
rule out the diagnosis. Lachman and drawer
(anterior/posterior) tests performed during physical
examination were negative.
2) Rheumatoid arthritis (RA) rational and supporting evidence
a.
Signs and symptoms of Rheumatoid arthritis include:
●
Pain or aching in more than one joint.
●
Stiffness in more than one joint.
●
Tenderness and swelling in more than one joint.
●
The same symptoms on both sides of the body.
●
Fever, fatigue or tiredness.
b.
Clinical examination:
Chronic inflammatory disease and rheumatoid arthritis can
harm more than simply joints. The illness might harm
numerous physiological systems, including the organs and
blood arteries.
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●
Labs: Anti-cyclic citrullinated peptide (anti-CCP) antibodies, increased
ESR or CRP levels, and RA factor are signs of an inflamed body.
●
Imaging tests: X-rays, MRI and ultrasound tests (CDC, 2020).
c.
Physical history and clinical findings for the differential diagnosis
Based on the patient's symptoms, which include unilateral
right knee discomfort that does not involve other joints, no
concomitant subcutaneous nodules, or joint stiffness lasting
longer than 30 minutes during the precise time (early
morning), this diagnosis is less plausible.
3) Leading diagnosis: Primary osteoarthritis of right knee
Osteoarthritis symptoms include one or more joints that experience pain,
swelling, stiffness, and a restricted range of motion when engaging in
activities like walking and climbing.
2. Diagnostics Plan
a.
Clinical physical examination: Flexibility with restricted range of motion or
crepitus while moving the afflicted joints, along with discomfort, edema, redness,
and pliability.
b.
Imaging tests: Anteroposterior/lateral and standing X-rays and MRI.
c.
Labs: Even though osteoarthritis cannot be diagnosed with a blood test, specific
procedures can help rule out other potential causes of joint pain, such as
rheumatoid arthritis.
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3. Treatment Plan:
a.
Pharmaceutical treatment:
●
Acetaminophen with mild to moderate pain relief.
●
NSAIDs: Ibuprofen (Advil), and Naproxen sodium (Aleve). NSAIDs for
topical use, such as diclofenac gel, are advised rather than oral
medications for people with GERD.
●
30 mg PO QD of duloxetine (Cymbalta) for one week, followed by 6 mg
PO once per week.
b.
Non-Pharmaceutical treatment:
●
Engage in non-weight-bearing exercise, such as aerobic or resistance
training or swimming.
●
Weight management for patients who fall into the category of being
overweight or obese.
●
Patellofemoral brace while activity for joint stability.
●
Exercise and self-management are guided by a physical therapist through
physical therapy.
c.
Surgical and other procedures:
●
Cortisone injection: Injection of a corticosteroid to reduce pain is often
only done three to four times a year because the drug can exacerbate joint
degeneration over time.
●
Lubrication injections: Hyaluronic acid injections by placing some
cushing in the joint.
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●
Knee replacement: If non-operative therapy and conservative treatment
cannot ease your problems, consult an orthopedic surgeon.
4. Education:
●
While therapy cannot cure OA, it can reduce discomfort, improve joint
functionality, and maintain a high standard of health.
●
Heat and cold therapies can improve joint discomfort, flexibility, blood
flow, and pain tolerance.
●
Support or assistive devices such as a cane or walker can help move
around safely, provide stability and lower pain.
●
Braces or shoe inserts can relieve strain on the area and support joints
(USDHHS, 2019).
5. Follow up:
Unless the treatment plans do not cause the symptoms to worsen, follow up in three
months.
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References
Cash, J. C., Glass, C. A., & Mullen, J. (2021).
Family practice guidelines
. Springer Publishing
Company.
Centers for Disease Control and Prevention. (2020a, July 27).
Rheumatoid arthritis (RA)
. Centers
for Disease Control and Prevention.
https://www.cdc.gov/arthritis/basics/rheumatoid-arthritis.html
Filbay, S. R., & Grindem, H. (2019, February).
Evidence-based recommendations for the
management of Anterior Cruciate Ligament (ACL) rupture
. Best practice & research.
Clinical rheumatology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723618/
U.S. Department of Health and Human Services. (2019, July 27).
Niams health information on
osteoarthritis
. National Institute of Arthritis and Musculoskeletal and Skin Diseases.
https://www.niams.nih.gov/health-topics/osteoarthritis/diagnosis-treatment-and-steps-to-t
ake