G.J. is a 71 yo overweight woman who presents to the Family Practice Clinic for the first time complaining of a long history of bilateral knee discomfort that becomes worse when it rains and usually feels better when the weather is warm and dry. "My arthritis hasn't improved a bit this summer though," she states. Discomfort in the left knee is greater than in the right knee. She has also suffered from low back pain for many years, but recently it has become worse. She is having difficulty using the stairs in her home.

The patient had recently visited a rheumatologist who tried a variety of NSAIDs to help her with pain control. The medications gave her mild relief but also caused significant and intolerable stomach discomfort. Her pain was alleviated with oxycodone. However, when she showed increasing tolerance and began insisting on higher doses of the medication, the physician told her that she may need surgery and that he could not prescribe more oxycodone for her. She is now seeking medical care at the Family Practice Clinic.

Her knees started to get significantly more painful after she gained 20 pounds during the past nine months. Her joints are most stiff when she has been sitting or lying for some time and they tend to "loosen up" with activity. The patient has always been worried about osteoporosis because several family members have been diagnosed with the disease. However, no clinical manifestations of osteoporosis have developed.

At age 23, the patient suffered a left knee injury in an MVA that did not require surgery. She also suffered a broken left hip 11 years ago when she fell on an icy sidewalk while visiting her sister in Michigan. Her hip seemed to have healed well as she has no significant symptoms that suggest hip joint involvement.

The patient has a 14-year history of OA, a 10-year history of HTN, a 4-year history of hypercholesterolemia, and a 4-year history of DM type 2. She also was hospitalized for an episode of diverticulitis two years ago. Her only surgery was a hysterectomy without oophorectomy 21 years ago. Menopause occurred at age 49, but she has never taken hormones.

• Father died from AMI at age 53
• Mother died from breast CA at age 80
• Patient has one brother, age 68, with HTN; one sister, age 74, who has severe allergies and has had two mitral valve replacements for rheumatic heart disease; and one sister, age 72, who also has OA
• Positive history of osteoporosis in mother and maternal grandmother

• Lives with her 72 yo sister in a 3-story townhouse near the beach
• Exercises regularly in the pool and, sometimes, in the ocean, but can no longer walk long distances daily as she has done in the past
• Has a well-balanced diet with plenty of fresh fruits and vegetables, whole grains, and dairy products, but admits to eating "too many sweets"
• Has Medicare but no other health insurance
• Does not smoke and drinks 1-2 cocktails or glasses of white wine every evening with her meal
• Hobbies include quilting, baking, and teaching piano to children

• Mild pain in right shoulder with lifting, carrying
• Low back pain with occasional "shooting pains" radiating to back of thigh
• Deep, aching pain in the pretibial area bilaterally and extending distally to the ankles and toes
• Patient denies any swollen, red, or hot joints, but notes "hard lumps" at the margins of the interphalangeal joints
• Patient denies numbness or weakness in her legs
• Patient denies pain or discomfort in her wrists and elbows
• Negative for headaches, neck stiffness, SOB, chest pains, urinary frequency or dysuria, constipation, diarrhea, nausea, loss of appetite, or significant changes in the appearance of her urine or stools
• Finger-stick blood glucose levels are usually around 180 mg/dL
• Occasional polyuria but no changes in vision

• Zolpidem 10 mg po Q HS PRN
• Atorvastatin 20 mg po Q HS
• Atenolol 25 mg po QD
• Lisinopril 40 mg po QD
• Metformin 250 mg po QD
• Glipizide 2.5 mg po QD
• Acetaminophen 1000 mg po TID
• High-potency multivitamin supplement with calcium, iron, and zinc po QD
• Calcium 600 mg with Vitamin D 125 IU supplement po BID with meals

Allergies

No known drug allergies

General

Alert, WDWN, overweight Caucasian female who appears slightly anxious but otherwise in NAD

Vital Signs

See Patient Case Table 78.1

Skin

• Warm and dry with normal turgor
• No petechiae, ecchymoses, or rash

• NC/AT
• PERRLA
• Funduscopic exam reveals sharp discs with no vascular abnormalities or papilledema
• (-) scleral icterus
• TMs intact
• Mucous membranes moist
• (-) lateral deviation of tongue, pharyngeal edema, or erythema

Neck/Lymph Nodes

• Neck supple
• (-)evidence of thyromegaly, adenopathy, masses, JVD, or carotid bruits

• Good chest excursion
• Lungs CTA & P

Heart

• Normal S₁ and S₂
• PMI normal at 5th ICS
• RRR
• No m/r/g

Abdomen

• Soft and non-tender without guarding
• (+)BS
• (-) organomegaly, bruits, and masses

• Symmetric
• No apparent masses, discharge, discoloration, or dimpling

Genitalia/Rectum

• Normal female genitalia
• (+) mild vaginal atrophy
• Normal anal sphincter tone
• Stool heme-negative

• Back with decreased flexion and extension
• Back pain radiating to right buttock with straight right leg raising >60°
• Full ROM at left shoulder, elbows, and ankles
• Mild left hip discomfort with flexion >90° and with internal and external rotation >45°
• Hips not tender to palpation
• Bilateral knee crepitus and enlargement but more pronounced in left knee
• Slight decrease in ROM and both Bouchard and Heberden nodes observed bilaterally during hand examination; no tenderness in finger joints
• No redness, heat, or swelling in joints
• Feet without breakdown, ulcers, erythema, or edema

• Oriented X 3
• Cranial nerves intact
• Sensory exam normal and symmetric to pinprick and vibration
• DTRs 2 + and equal bilaterally except for 1 + Achilles reflexes bilaterally
• Strength 5/5 in both upper extremities; 4/5 in lower extremities
• Gait slow but without specific deficits
• Coordination WNL
• No focal deficits
• (-) Babinski bilaterally

See Patient Case Table 78.2

See Patient Case Table 78.3

Lumbosacral spine

• Advanced degenerative changes with disk space narrowing and osteophyte formation at L3-4 and L4-5
• No evidence of compression fracture

Left hip

• Mild-to-moderate degenerative changes with mild osteophytosis of femoral head
• Slight narrowing in joint space

Right and left knees

• Moderate degenerative changes with joint space narrowing, subchondral sclerosis, and bone cysts
• No radiographic evidence of osteoporosis or joint effusions

Right shoulder

• Mild degenerative changes with bone spurs at head of humerus
• Slight narrowing in joint space

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Abbreviations

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Abbreviations

Muscular-skeletal system physiology

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Muscular-skeletal system physiology