NR 601 Week 4 DQ2 -Mrs R Case Study

NR 601 Week 4 DQ2 -Mrs R Case Study

NR 601 Week 4 DQ2 -Mrs R Case Study

Week 4 DQ 2 NR 601

Patient Information:

Mrs. R., 66 y/o F

1. (Subjective)

CC – The pain has been “getting worse” in the left hip area with daily activities such as walking, bending, standing, and squatting.

When asked to describe where the pain occurs, she places her fingers around the anterolateral hip region. She denies any back pain, or pain in the posterior hip or along the lateral thigh. Denies any previous injury, stumbling, tripping or falling. She states that the pain has been getting gradually worse and is almost constant if she walks or stands for a long period of time. She denies back pain, numbness, tingling, or weakness in the extremities. She reports taking Ibuprofen 800 mg approximately 3 times/week whenever she has significant hip pain. She is concerned that she doesn’t know what is causing the pain and that she is having to take increased doses of ibuprofen to manage the pain. She reports a current pain level of 8/10 on the pain scale.

Background:

She walks approximately 1 mile a day. She recently retired as an office manager 4 years ago.

HPI:

O: Onset: How long have you had you symptoms? Did the symptoms come on suddenly? The pain has been getting gradually worse and is almost constant if she walks or stands for a long period of time. Any recent medication or environment changes?

L: Location:  Point to where you are you hurting and rate your pain on a scale of 0 to 10. Pain is rated a 8/10 in the left hip area. Are you hurting in any other area of your body? Pt denies any back pain, or pain in the posterior hip or along the lateral thigh. Are you allergic to any medications or foods? Are your joints stiff in the morning? If so, for how long? Have you had any recent infections or injuries? Pt denies any previous injury, stumbling, tripping or falling.

D: Duration: Are your symptoms continuous or intermittent?  Have you ever had symptoms like this before? Have you or any other family members been diagnosed with arthritis?

C: Characteristics/Associated Symptoms: Are there any other symptoms other than the anterolateral hip region? Patient denies numbness, tingling or weakness in the extremities. Has there been any pattern to your symptoms? Do you have any general symptoms that seem to affect your whole body, such as fatigue, weight loss, or fever? Have you noticed any swelling, warmth or tenderness to your extremities? Have you noticed any bumps on your fingers or hands?

A: Aggravating: Have you noticed anything that makes your pain worse? It becomes worse with walking, bending, standing and squatting. Do exercises help your pain or make it worse? Have you tried any kinds of exercises? Patient walks approximately 1 mile a day. Are there any other exercises you have tried?

R: Relieving Factors: Does anything make your pain better? Ibuprofen OTC in increased doses (800mg approximately 3x’s/week) helps to manage the pain.

T: Treatments: Have you used any other OTC or prescription medications, creams, heat or ice for your symptoms? Other than your listed Ibuprofen, are there any other medications such as anti-inflammatory or herbal products that you have taken? If so what was the name, last time you consumed these and the dosage?

S: Severity: What normal daily activities does the pain affect? Do you have any difficulty in walking or performing your normal daily routines?

NR 601 Week 4 DQ2 -Mrs R Case Study

Current Medications: Ibuprofen 200-800 mg prn for hip pain

PMH: Unremarkable

Immunizations: All vaccines are current

Screenings: Never had a colonoscopy, last mammogram was 5 years ago

Surgical Hx: Cholecystectomy 20 years ago, Hysterectomy 10 years ago

Social Hx: Has an occasional glass of wine with dinner, does not smoke

Focused ROS and Physical Exam: constitutional, HEENT, cardiovascular, respiratory, integumentary, gastrointestinal, musculoskeletal, neurological

ROS:

CONSTITUTIONAL: Alert, oriented and no distress noted. Positive for pain.

HEENT: No complaints noted

CARDIOVASCULAR: No complaints noted

RESPIRATORY: No complaints noted

INTEGUMENTARY: No complaints noted

GASTROINTESTINAL: No complaints noted

MUSCULOSKELETAL: Positive left hip pain; negative for back pain

NEUROLOGICAL: Negative for numbness, tingling and weakness in the extremities

Objective:

Physical examination:

Vital Signs:

BP 128/84, HR 80 R 20, Temp 98.5 Ht 5’3”, Wt 130 pounds

General: no acute distress

HEENT: Head normocephalic without evidence of masses or trauma. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear canal without redness or irritation, TMs clear, pearly, bony landmarks visible. No discharge, no pain noted. Neck negative for masses. No thyromegaly. No JVD distention

Skin: intact

CV: S1 and S2 RRR, no murmurs, no rubs

Lungs: Clear to auscultation

Abdomen: Soft, nontender, nondistended, bowel sounds present all 4 quadrants, no organomegaly, and no bruits

Musculoskeletal: No pain to palpation; Antalgic gait noted when patient rises from seated position to standing and begins to walk. Active and passive ROM decreased with stiffness

Neuro: Sensation intact to bilateral upper and lower extremities; Bilateral UE/LE strength 5/5.

Assessment:

• Intentionally omitted in this preview.

Plan:

• Intentionally omitted in this preview.

NR 601 Week 4 DQ2 -Mrs R Case Study

Pharmacological Strategies:

• Intentionally omitted in this preview.

Non-pharmacological strategies:

• Hydrotherapy
• Warm showers
• Paraffin baths
• Cold therapy
• Physical therapy
• Occupational therapy
• Acupuncture
• Balneotherapy
• TENS unit techniques

Patient Education:

• Keep active/moving
• Avoid stressing the joints
• Make home modifications to ensure safety
• Be aware of emotional burdens and changing of emotions
• Enroll in land-based and water-based exercise programs
• Maintain a healthy weight by eating a diet low in saturated fats, trans fats, and refined and processed foods, increase vegetables, whole grains and lean proteins

Follow-up and referrals:

• Monitor progression of the disease
• Use medications as prescribed
• Monitor for patients response to treatment
• Watch for possible side effects and report if any occur
• Follow up in one month for evaluation and lab work
• Refer to orthopedic surgeon if osteoarthritis fails to respond to medical management

 

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NR 601 Week 4 DQ2 -Mrs R Case Study

References:

JOHN J. WILSON, MD, MS, and MASARU FURUKAWA, MD, MS, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. (2014, January). Evaluation of the Patient with Hip Pain. Retrieved November 15, 2016, from http://www.aafp.org/afp/2014/0101/p27.html

Svege, I., Fernandes, L., Nordsletten, L., Holm, I., & Risberg, M. A. (2016). Long-Term Effect of Exercise Therapy and Patient Education on Impairments and Activity Limitations in People With Hip Osteoarthritis: Secondary Outcome Analysis of a Randomized Clinical Trial. Physical Therapy, 96(6), 818-827.

Tsui FW (Apr 2012). “Genetics and mechanisms of crystal deposition in calcium pyrophosphate deposition disease”. Curr Rheumatol Rep. 14 (2): 155–60. doi:10.1007/s11926-011-0230-6. PMID 22198832

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). (2015). Retrieved November 15, 2016, from http://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Western-Ontario-McMaster-Universities-Osteoarthritis-Index-WOMAC

Wilson, J. J., & Furukawa, M. (2014). Evaluation of the patient with hip pain. American Family Physician, 89(1), 27-34. Retrieved from: http://www.aafp.org/afp/2014/0101/p27.html