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Musculoskeletal Cases

Musculoskeletal Cases. Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012. History of Present Illness.

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Musculoskeletal Cases

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  1. Musculoskeletal Cases Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

  2. History of Present Illness A 70 year old woman is brought to your clinic by her daughter for an evaluation. Her daughter is concerned that the patient is not able to care for herself independently. The daughter notes that her mother frequently appears only partially dressed and has stopped wearing a brassiere. She becomes defensive with the daughter when this is pointed out to her. The patient has been living on her own since the death of her husband 4 years earlier. The daughter relates that her mother is losing weight and seems to have difficulty with cooking. On meeting this patient you notice that it takes a full 3 minutes for her to get up out of her chair and walk across the examining room.

  3. Past Medical History Illness: Osteoarthritis Hypertension No Surgery Medications: Aspirin 81 mg po qd Multivitamin qd

  4. Social History Widowed for 4 years No tobacco/No ETOH Worked in textiles Mother of 4 children Baptist Schooled through the 8th grade.

  5. ROS (Review of Systems) Admits to occasional bowel incontinence and frequent urinary incontinence Other review unremarkable

  6. Physical Exam • VS: T 98.4° BP 120/80 Resp18 P 66 and regular • HEENT- unremarkable • Neck-Supple, no JVD, Bruit, nor Lymphadenopathy • Heart RRR w/o murmur

  7. Physical Exam • Lungs: clear to auscultation & percussion • Abdomen: soft with normal BS. No masses. • Extremities- • large prominent bony swelling in patient’s distal interphalangeal joints • Decreased ROM in internal rotation of the bilateral shoulder joint • Decreased ROM in external and internal rotation of hip joints

  8. Physical Exam • Neurologic • DTRs 2/4 and equal bilaterally in the upper and lower extremity • Muscle Strength 5 + in bilateral upper extremity but 4 + in bilateral hip extension. • Normal in all other areas • MMSE- 29/30

  9. Clinical Case Questions • The swellings on this patients distal interphalangeal joints are most likely • Bouchard’s nodes • Heberdon’s Nodes • Cysts due to Hemochromotosis • Rheumatoid arthritis • Chronic Synovitis

  10. Clinical Case Questions 2. Of the four ADL’s (Activities of Daily Living) this patient exhibits problems with how many? • 1 • 2 • 3 • 4 • none

  11. Clinical Case Questions 3. Do you think this patient will pass the get up and go test? Why or why not?

  12. Clinical Case Questions 4. Osteoarthritis is a disease which • Affects bone primarily • Affects cartilage primarily • Occurs in the 1stthree decades of life • Is never “crippling” • Is not progressive

  13. Clinical Case Questions 5. This patient is completely mentally intact. What would explain her changes in behavior as far as her self grooming is concerned? • Patient is depressed • Patient is unable to reach her body parts for dressing and grooming due to DJD, stiffness, and pain. • Patient has neglect due to mental deterioration • There is no “good explanation” of patients behavior • Would need X-Ray evaluation and lab prior to making an educated guess.

  14. Answers • b (Heberdon’sNodes) • d (4) She moves about poorly, dresses poorly, eats poorly, and toilets poorly. For those who split toileting into 3 components, she is 5/6 since she is apparently continent. • The get up and go test will be failed due to the 3 minute observation already made. • b (Affects cartilage primarily) • b This woman is dysfunctional due to the effects of DJD preventing mobility, grooming, eating, preparing food, dressing, and other activities.

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