Patient Information
K. H., 69 years old, female, Asian American S.
CC frequent numbness in upper and lower limbs, mild neck pain, and moderate pain in the lower spine.
HPI: 69-year-old A.A. female.
Location: neck
Onset: 11 months ago.
Character: nagging, stiffness in the spine.
Associated signs and symptoms: headaches, frequent numbness in feet and arms, occasional disorientation.
Timing: in the morning, after sleeping, and following physical activities.
Exacerbating/ relieving factors: prolonged sitting exacerbates the discomfort, and replacing the mattress and pillows slightly relieves the symptoms.
Severity: 3/10 pain scale.
Current Medications: Acetaminophen – 1 dose per day.
Allergies: Medication – none; food – shellfish (urticaria, angioedema), environmental – none.
PMHx: Last tetanus – booster shot in 2014;
Past illnesses and surgeries: in 2015, the patient fractured her hip following a fall, and the recovery was successful. In 2010, the patient underwent kidney stone removal surgery. In 1973, the patient had a surgical intervention for appendicitis.
Soc Hx: The patient is retired and lives alone in a private residence, formerly worked as an accounting consultant for 21 years. K. H. tries to maintain an active, healthy lifestyle, as suggested by her physician, following the 2015 hip fracture recovery. She smoked for 31 years but quit in 2017. The patient’s main hobbies include power-walking, floral decorations, and piano practicing. Since the fall in 2015, K.H. has taken the corresponding precautions to prevent such incidents at home. The patient’s house is equipped with extra railings at the staircases and in the bathroom, as well as emergency contact buttons and smoke detectors. The patient remains in close contact with her children and younger siblings, who visit her at least once in two weeks.
Fam Hx: The patient currently does not have any known genetic life-threatening conditions. However, the family history includes cases of lethal cancer outcomes: father (age 61, lung cancer), grandfather (age 77, colon cancer), uncle (age 55, lung cancer). The patient’s mother deceased at the age of 88 due to Covid-19-associated pneumonia. The patient’s younger brother is currently treated for a non-cancerous brain tumor (glioma).
ROS
GENERAL: No weight loss, fever, chills, weakness, or fatigue. Slight height loss
HEENT: Eyes: No visual loss, double vision, or yellow sclerae. Occasional blurred vision. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: No discomfort during urination.
NEUROLOGICAL: Occasional headaches and dizziness, frequent numbness and tingling in the extremities. No signs of syncope, paralysis, or ataxia. No change in bowel or bladder control.
MUSCULOSKELETAL: Mild-to-moderate pain throughout the spine, particularly present in lower sections and the neck. Frequent stiffness of the neck.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: Node size within the age norm No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Shellfish causes urticaria and angioedema. No history of asthma, eczema, or rhinitis.
O.
Physical exam: General: The patient’s movements are restrained and cause visible discomfort. EENT: the vision is clear and unimpaired. Musculoskeletal system: The neck is not swollen, but the patient struggles to lean it over 45o. The right shoulder is visibly higher than the left one. The spinal curvature is observed but not alarming. Back muscles are tense. The legs are
Diagnostic results: X-Ray examination will be needed for a more detailed assessment. MRI diagnostics are required to enable precise data regarding potential spine conditions.
A.
Differential Diagnoses
Cervical spondylosis
Osteoarthritis
Facet arthropathy in L4-S1 vertebrae
Mild loss of vertebral body height of L4 and L5
P.
Following the initial assessment of the patient, a list of differential diagnoses was drafted. Based on the constant presence of such symptoms as extremity numbness, the patient is likely to have a mild form of cervical spondylosis. Lv et al. (2018) state that the prevalence of this condition is rather significant in older adults of Asian origins. Furthermore, the likelihood of the condition positively correlates with the patient’s age. Considering her ethnic background and age of K.H., she is likely to have cervical spondylosis. However, the location of the back pains suggests the development of facet arthropathy in L4-S1 vertebrae as an underlying condition. In addition, the patient reports a visible decrease in height, which indicates a mild loss of vertebral body height of L4 and L5.
The patient encountered the first symptoms about 11 months ago. The first examination at a different facility resulted in a similar conclusion. The previous medical specialists noted that the condition of K.H. was normal for her age and proposed paracetamol-based medication to relieve the symptoms upon need. Even though the condition did not progress significantly, the symptoms persisted throughout the year. The patient demonstrated a good level of personal health awareness and decided to address a different medical unit in order to prevent further complications. Alizada et al. (2018) refer to cervical instability as the primary cause of cervical instability and impaired mobility, especially in older patients. Therefore, K.H. made the correct decision to seek more profound treatment. The contemporary practice recognizes cervical disc arthroplasty as an effective method of addressing the issue and preserving the patient’s mobility (Chang et al., 2018). However, such an intervention is rather serious, and K.H. may not need such strong measures so far. Accordingly, the consecutive treatment plans will be based on the preservation of the patient’s mobility through pharmacology and physiotherapy. Overall, this case highlights the importance of evidence-based practice, as the details of it become clearer in the context of the patient’s ethnic and age-related variables.
References
Alizada, M., Li, M. R., & Hayatullah, G. (2018). Cervical instability in cervical spondylosis patients.Der Orthopäde, 47, 977-985. Web.
Chang, C. C., Huang, W. C., Wu, J. C., & Mummaneni, P. V. (2018). The option of motion preservation in cervical spondylosis: Cervical disc arthroplasty update.Neurospine, 15(4), 296-305. Web.
Lv, Y., Tian, W., Chen, D., Liu, Y., Wang, L., & Duan, F. (2018). The prevalence and associated factors of symptomatic cervical spondylosis in Chinese adults: A community-based cross-sectional study.BMC Musculoskeletal Disorders, 19. Web.