Chief Complaint (CC): “I feel pain in my right hip that radiates to the right foot”
History of Present Illness (HPI): a 70-year-old female presents with right hip pain that occurred a week ago. This recent symptom is evaluated by the patient as tingling and numbing, while the associated symptoms include pain in the right foot. No aggravating factors are noted, and AB used Motrin as a pain reliever. The severity level is 8/10.
Medications:
- Aspirin 81 mg EC 1 tab daily
- Cartia XT 240mg daily
- Cardizem CD 240 mg daily
- Lasix 20 mg daily
- Flonase 50 mcg 2 sprays every 4 hours as needed
- Lipitor 10 mg daily
- Florastor 250 mg daily
- Terazosin HCL 5mg at bedtime
- Multivitamin 1 tablet daily
Allergies: Seasonal allergy.
Past Medical History (PMH): coronary disease, rheumatoid arthritis, hypertension, and osteoarthritis.
Past Surgical History (PSH): appendectomy in 2014.
Sexual/Reproductive History: sexually inactive.
Personal/Social History: the patient denies tobacco, alcohol, and illegal drug use. She handles the Activities of Daily Living (ADLs) but needs assistance with the Instrumental Activities of Daily Living (IADLs). AB tries to eat healthily yet she does not practice physical exercises.
Immunization History: influenza and pneumonia vaccines a year ago.
Significant Family History: AB’s parents died in the car accident, both of them had cardiovascular health issues. Her grandfather had hypertension and died from heart attack, and grandmother was diagnosed with rheumatoid arthritis and died from stroke. AB’s three daughters have hypertension, while one of them has diabetes.
Lifestyle: AB is religious and visits the local church once a week. Her family members cannot support her daily activities since they live in a different city, yet they provide financial assistance.
Review of Systems
General: the patient denies recent weight loss or gain, night sweats, and fever.
Cardiovascular/Peripheral Vascular: negative for edema, palpitations. orthopnea, and chest pain.
Musculoskeletal: reports tingling and numbness in the right hip and foot; no recent traumas.
Allergic/Immunologic: seasonal allergy, controlled.
Objective Data
Physical Exam
Vital signs: B/P 140/80, right arm, sitting, regular cuff; P 62 and regular; T 98; RR 20; non-labored; Wt: 158 lbs; Ht: 5’7; BMI 24.
General: The patient appears attentive and oriented during the examination. She seems to be aware of her health problem and provides full information. The reactions, dressing, and facial expressions are appropriate.
Heart/Peripheral Vascular: regular heart rate, no murmur or pedal edema; 2+ dorsalis pedis pulses bilaterall.
Musculoskeletal: X-ray results show cartilage loss; MRI scan presents no inflammation in soft tissues and bones; joint fluid analysis shows that the pain is caused by the joint instability and torn cartilage (Pap & Korb-Pap, 2015).
Assessment
- Osteoarthritis. This chronic disease in which damage to the cartilage and surrounding tissues is observed may be regarded as the primary diagnosis for the given patient. The disease is characterized by pain, stiffness, and loss of function in joints caused by the loss of cartilage (van Walsem et al., 2015). The clinical assessments support this diagnosis. In addition, cartilage lining the surface of the joint becomes thinned with age that also leads to osteoarthritis (Pap & Korb-Pap, 2015).
- Rheumatoid arthritis. It is a chronic degenerative joint disease, which is based on a violation of the synthesis and degradation of the matrix of the articular cartilage. Accoridng to van Walsem et al. (2015), the most significant risk factors for its development are female sex and elderly patients. Inflammation of joints is manifested by pain, swelling, and restriction of movements in them. Since the joint fluid analysis shows no inflammation, this diagnosis cannot be considered primary even though the patent’s history contains rheumatoid arthritis.
- Crystalline arthropathy. Microcrystalline arthritis is caused by crystals of gout and / or calcium pyrophosphate. The disease manifests as pseudo-gout or acute arthritis (Kourilovitch, Galarza-Maldonado, & Ortiz-Prado, 2014). The absence of the deposition of sodium urate crystals in the joints or joint fluid observed by polarizing light microscopy eliminates the diagnosis.
- Psoriatic arthritis. This type of arthritis is diagnosed in patients having psoriasis, while problems with joints may begin before the skin disorder (Kourilovitch et al., 2014). Swollen fingers, lower back pain, and foot pain are the key symptoms, of which only the latter is present.
Plan
Treatment Plan
The application of the nonsteroidal anti-inflammatory drug (NSAID), cyclooxygenase-2 inhibitors, is relevant to the given patient, taking into account her age, concomitant diseases, and pain severity (van Walsem et al., 2015). Namely, Celebrex should be prescribed (400 mg initially to relive acute pain and 200 mg daily for 14 days). The physical therapy – stretching exercises allow keeping healthy cartilaginous tissues, increasing the range of movements in the joint, and strengthening the nearby muscles. The patient should be referred to a physical therapy specialist and an occupational therapist. The follow-up visit should be planned within the next three weeks.
Health Promotion
Yoga and tai chi are beneficial to reduce pain and stress. The nurse assisting the patient should be aware of her diagnosis and adjust care accordingly. Healthy nutrition and family support are also important to help AB feel more comfortable.
Disease Prevention
As an older adult patient, AB should be explained that she may improve her quality of life by timely screenings and vaccinations (Resnick, 2016). Healthy nutrition may help the patient to avoid many chronic diseases such as diabetes or Alzheimer’s disease.
Reflection
From this experience, I have learned that geriatric patients have specific needs that should be considered while diagnosing them and identifying treatment options. Due to their age and vulnerability to chronic diseases, medication and alternative therapies should be selected with higher precision (Seidel et al., 2011). I agree with my preceptor, and I would also provide the blood test to analyze specific indicators and recommend personal training with yoga instructors.
References
Kourilovitch, M., Galarza-Maldonado, C., & Ortiz-Prado, E. (2014). Diagnosis and classification of rheumatoid arthritis. Journal of Autoimmunity, 48, 26-30.
Pap, T., & Korb-Pap, A. (2015). Cartilage damage in osteoarthritis and rheumatoid arthritis—Two unequal siblings. Nature Reviews Rheumatology, 11(10), 606-615.
Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby.
van Walsem, A., Pandhi, S., Nixon, R. M., Guyot, P., Karabis, A., & Moore, R. A. (2015). Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or rheumatoid arthritis: A network meta-analysis. Arthritis Research & Therapy, 17(1), 66-84.