discussion

Name: U.H

 Patient Encounter No: N/A

Date: 8/1/2018

Age: 58 yrs

Sex: Female

SUBJECTIVE

CC:  “There is pain in my knees and toes.”

HPI: U.H was carrying out her usual activities about two months ago when she started to feel pain in her knees. The pain was not intense to warrant immediate medical care, and thus, she did not attend any health facility. One month ago, she started to feel pain in her fingers and toes. The pain progressed until one week ago when she could experience stiffness, especially in the morning. Four weeks ago, the toes began to “swell,” and she could lose flexibility when walking. She wants to understand the cause of her illness.

Medications: Not on any medicine.

PMH

Allergies: Denies allergies.

Drug Intolerances: None.

Chronic illnesses: Never suffered from any.

Major Trauma: Reports none.

Surgical operations: None has been done previously.

Admissions: Never been admitted.

Family History: The father died due to a stroke, but the mother is alive and well. Her four siblings are all alive and well except for one of them who underwent a mastectomy due to a breast malignancy.

Social History: Never takes alcohol. Does not smoke.

Review of Systems

General: Positive for weight loss and fever. Denies night sweats and chills.

Cardiovascular: Positive for lower left extremities edema at the knee. Denies PND and palpitations.

Skin: Positive for redness of the skin at the joints. Denies rashes.

Respiratory: Denies dyspnea and a cough.

Eyes: Denies the use of lenses or blurring.

Gastrointestinal: Denies stomach pain, bloating after meals, or flatulence.

Ears: Denies pain or tinnitus.

Genitourinary: Denies dyspareunia, polyuria, foul-smelling discharge, or dysuria.

Nose/Mouth/Throat: Denies dental diseases, or nosebleeds.

Musculoskeletal: Positive for pain in the phalangial and knee joints. Positive for stiffness and loss of flexibility, especially in the morning.

Breast: Denies lumps.

Neurological: Denies seizures or blackout spells.

Heme/Lymph/Endo: Denies swollen glands, polyphagia, and she had a negative HIV test last month.

Psychiatric: Denies sleeping difficulties or suicidal ideations.

OBJECTIVE

Weight: 115 Height: 5’ 4.’’

BMI: 19.7

Temp: 98.7 F

Pulse: 80

Resp: 19

BP: 122/78mmHg

Appearance: Alert and not in distress.

Skin: No rashes. Warm.

Head: No Evenly distributed hair. No lesions. Ears: Canals are patent. Eyes: PERRLA. Neck: Supple. Mouth: No sores on the tongue or gums. Nose: Normal turbinates. Throat: No exudates.

Cardiovascular: Edema +1 on left lower extremity. No arrhythmias, or murmurs.

Respiratory: Easy breaths. No wheeze.

Gastrointestinal: No abdominal tenderness. No hepatomegally.

Breast: No tenderness or masses.

Genitourinary: No masses, foul-smelling discharge, or lesions on the vulva.

Musculoskeletal: Reddened joints, tenderness of knee joints upon palpation, leg stiffness, and limited ROM of lower limbs.

Neurological: Waddling gait.

Psychiatric: Dressed in a blue dress, maintains eye contact and answers all questions.

Lab Tests

None

Special Tests: X-ray shows eroded cartilage and reduced spaces between bones at the joints.

 Diagnosis

 Differentials

1. Rheumatoid Arthritis (M06.9). This diagnosis could be present since the client complains of pain in the joints that hurt when she moves. She has also experienced weight loss in the past three weeks, and she currently has fatigue. Objectively, the joints are tender, swollen, and the skin around them is warm. She confirms that her joints are stiff in the morning when she wakes up. According to Pisetsky (2017), patients with rheumatoid arthritis present with the stiffness of the joints that may also be painful and warm. This assertion justifies this diagnosis.

2. Arthritis Mutilans (L40.52). The presenting symptoms demonstrate that the patient could be suffering from Arthritis Mutilans. According to Kaeley, Eder, Aydin, Gutierrez, and Bakewell (2018), patients with this diagnosis may present with swollen joints and pain. In this case, the objective data shows that the patient has swollen phalanges and toes. The subjective data reveals that the swollen joints are causing pain. These problems signify the likelihood of Arthritis Mutilans.

3. Gout (M10.9). Gout may be present, in this case, considering that the patient complains of the symptoms that are related to its diagnosis. For example, subjectively, the patient complains of joint pains both in the fingers and in the toes. Objectively, the skin around the joints is reddened and warm thereby proving that inflammation has occurred. The patient also has a limited range of motion. According to Saigal and Agrawal (2015), joint pain and inflammation and pain with limited range of motion may signify a positive diagnosis of gout.

Osteoarthritis (M19.90). Although all the three possible diagnoses may be present, the most appropriate diagnosis for this patient is osteoarthritis. In the subjective data, the patient complains of pain that occurs in the joints when she moves. Palpation of the joints reveals tenderness, and the patient experiences stiffness when she walks. The lower extremities have limited range of motion. These symptoms may also be present in the other diagnoses, but in this case, the patient has bone spurs. The X-ray reveals a narrow space between bones in the joints. According to Sharma (2016), bone spurs and erosion of cartilage between bones at the joint is an indication of osteoarthritis. Thus, this patient has this diagnosis.

Plan

Further testing: MRI to assess the extent of joint damage.

Medications: The focus of medication management for this patient is on the management of her symptoms, especially pain. According to Pelletier, Martel-Pelletier, Rannou, and Cooper (2016), acetaminophen is therapeutic for patients with this condition as relieves mild to moderate pain. The patient has been given acetaminophen tablets, and she will take one gram every eight hours for pain relief. The patient also has inflammation, and thus, naproxen sodium has been given to relieve it. According to Pelletier et al. (2016), this drug relieves not only pain but also inflammation. She will take 750mg once a day.

Education: The patient has been told that taking medications as appropriate may not heal her condition but can improve her symptoms. Therefore, she has been taught the importance of complying with the provided analgesics. According to Nejati, Farzinmehr, and Moradi-Lakeh (2015), physical exercise is crucial in reducing pain and increasing the range of motion. The patient has been advised to adhere to the designed exercise plan and to report if she experiences any issues with following it.

Non-medication Treatments: The provided data reveals that the patient does not engage in physical exercise. Nejati et al. (2015) recognize physical activity as crucial in the management of osteoarthritis. Therefore, the patient has been helped to create a regular exercise plan that involves jogging or walking in the morning and evening for a minimum of 30nminutes daily. It is expected that this therapy will enhance his joint function.

Follow-up: Further assessment and tests will occur on the seventh day, and thus, the patient must come on that day. Compliance with medications will be evaluated on that day, and the patient will explain any challenges she will have experienced with any given therapy. Most importantly, the patient will explain if her symptoms will have improved to assist in adjusting the treatment regimen.