Osteoarthritis
Wear and Tear (Level II)
PATIENT PRESENTATION
Chief Complaint
"My joints are killing me; I need something else for this pain."
HPI
Donald Abernathy is a 73-year-old man who presents to the Ambulatory Care Clinic for his
regular follow-up appointment complaining of increasing pain in his lower back, hips, and right
knee. Six months ago, the patient was started on acetaminophen 500 mg tablets, two tablets
four times daily, and has been taking more than prescribed over the last few weeks. (He
admits to taking three 500 mg tablets four times daily.) The patient is in clinic today
complaining that this increased dose has not been working, and that he has been in moderate
to severe pain for the last 3–4 weeks. He has been adherent to all other drug therapies.
The patient is a veteran who served in the Korean conflict and worked in a factory for 35 years
after his time in the military. His factory job often puts strain on his back and legs due to
heavy lifting. Since retiring 15 years ago, the patient states that he has put on excess weight
and developed many medical problems that are frustrating him.
PMH
OA x 18 years
Obesity x 15 years
Type 2 DM x 5 years
Hyperlipidemia x 5 years
HTN x 10 years
BPH x 4 years
PSH
Appendectomy 27 years ago
FH
Mother died at 81 of CVA; father died at age 75 secondary to pancreatic cancer; no siblings
SH
Retired; receives all medications from the VA; occasional alcohol, no tobacco or illicit
drug use
Married; lives with wife at home; has one daughter who is a registered nurse
Meds
Lisinopril 10 mg po Q AM
Metformin 500 mg po BID
Acetaminophen 500 mg po 2 tablets four times daily
Amitriptyline 25 mg po at bedtime for sleep
Loratadine 10 mg po PRN
Terazosin 2 mg po at bedtime
All
Sulfa—hives
Egg products
ROS
Positive for pain and stiffness in right knee; low back pain with "shooting pains" radiating to
the buttocks and groin area; "deep, boring" pain originating in the right pretibial area and
extending distally to the right ankle and toes. Negative for headache, neck stiffness, joint
swelling, or erythema; no SOB or palpitations; has been experiencing urinary hesitancy and
occasional constipation; no diarrhea, no tarry stools. Fingerstick blood glucose concentrations
have been running in the low 140s (he checks them once to twice per week). No blurred
vision.
Physical Examination
GEN
Well-developed, obese, Caucasian male slightly uncomfortable, but otherwise in NAD
VS
BP 148/88, P 84, RR 16, T 37.1°C; Wt 225 lb, Ht 5'11''. No orthostatic changes.
SKIN
Warm, dry; LE—shiny, somewhat discolored areas on the pretibial area bilaterally, consistent
with venous stasis dermatitis
HEENT
NC/AT; PERRLA; funduscopic exam reveals sharp disks; mild AV nicking, but no hemorrhages
or exudates; no scleral icterus; TMs intact; mucous membranes moist; poor dentition with
gingival erythema; no lateral deviation of tongue; no pharyngeal edema or erythema.
NECK/LYMPH NODES
Supple; no thyromegaly or lymphadenopathy; no carotid bruits
LUNGS
CTA
CV
Distant heart sounds, Normal S1 and S2; PMI at 5th ICS/MCL; RRR; no MRG; no JVD or HJR
ABD
Obese, soft, nontender; no guarding; (+) BS; unable to assess liver size upon palpation
GENIT/RECT
Prostate gland slightly enlarged; normal sphincter tone; guaiac (–) stool in rectal vault
MS/EXT
Back pain radiating to right buttock with straight leg raising at 60°; right hip pain with flexion
>90° and with internal and external rotation >45°; both hips tender to palpation; right knee
(+) crepitus; right ankle with full ROM, no swelling or edema.
NEURO
Oriented x 3; normal affect; appears at times to alternate between apathy and
anger/frustration; CN II–XII intact; DTRs equal bilaterally except for slightly diminished
Achilles reflexes bilaterally; no focal deficits; gait impaired secondary to hip and knee pain.
Slightly decreased sensation to pinprick and vibration on the distal half of right foot. Babinski's
downgoing.
Labs
Na 135 mEq/L
Hgb 12.8 g/dL
AST 38 IU/L
Ca 11.2 mg/dL
K 4.7 mEq/L
Hct 36.7%
Alk Phos 96 IU/L
Phos 4.5 mg/dL
Cl 98 mEq/L
WBC 4.5 x 103/mm3 T. prot 7.4 g/dL
T. chol 206 mg/dL
CO2 26 mEq/L
Plt 286 x 103/mm3
HDL chol 33 mg/dL
BUN 15 mg/dL MCV 85.3
m3
Alb 4.4 g/dL
Uric acid 7.2 mg/dL LDL chol 137 mg/dL
SCr 1.6 mg/dL MCH 28.4 pg
ESR 18 mm/h
TG 184 mg/dL
Glu 248 mg/dL MCHC 34.5 g/dL
CRP 0.2 mg/dL
A1C 8.1%
UA
SG 1.011; pH 6.5; WBC (–), RBC (–), leukocyte esterase (–), nitrite (–), 1+ protein.
Microscopic examination reveals 2 to 5 epithelial cells/hpf and no bacteria.
X-Rays
Lumbar spine: advanced degenerative changes at L3-4 and at L4-5.
Right hip: moderate degenerative changes with some spurring of the femoral head
and slight decrease in joint space.
Right knee: moderate degenerative changes. No effusion.