NGN: Musculoskeletal Case Study Questions Adaptive Quiz (EAQ)- Sherpath

Musculoskeletal – Patient 1

A 45-year-old client presents to the outpatient clinic reporting worsening numbness and tingling of both hands with a 2-day history of dysuria and polyuria. The client has worked the last 16 years as a secretary and has a history of asthma, obesity, hypothyroidism, and hypertension. The client also reports chronic fatigue and feels stressed and overworked. The client is alert and oriented, and neurologic exam is negative. Vital signs are temperature 98.6^oF (37^oC), heart rate of 78 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 144/86, and pulse oximetry reading of 96%.

• Urinalysis
• Urine culture and sensitivity
• Amlodipine 5 mg po daily
• Levothyroxine 50 mcg po daily
• Albuterol MDI

X-ray bilateral hands show no fractures or abnormalities.

done

That’s right!

Rationale:

Potential Conditions Carpal tunnel syndrome is a musculoskeletal condition affecting the median nerve as it passes through the carpal tunnel. It is commonly associated with pain and paresthesia of the wrist and less commonly with weakness. Osteoporosis can be associated with fractures and is more common in older adults. A fracture would have been detected on the x-ray and associated with swelling and more pain. Rheumatoid arthritis usually presents with painful, swollen joints that are most painful in the morning with characteristic deformities, such as swan neck deformity and boutonniere deformity. Relevant Cues Tingling and numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. Fatigue may be related to the hypothyroidism or work-related stress. Polyuria and leukocytosis suggest a possible urinary tract infection. Additional Assessments Classic assessment techniques for carpal tunnel syndrome include eliciting Tinel sign and performing the Phalen maneuver. Ballottement can be used to determine the presence of an effusion in the knee. Trendelenburg sign is found with weak hip abductor muscles. The Hawkins Kennedy test is used to assess for rotator cuff inflammation or tear.

Musculoskeletal – Patient 2

A 52-year-old female who is obese is admitted to hospital Monday by Orthopedics for left total knee arthroplasty to be performed on Tuesday. She had initially presented to her primary healthcare provider 5 months ago for chronic left knee pain that has been worsening. She reports pain that worsens over the course of the day in both knees for several years. She is a former college athlete, but her activity level has decreased in the past 2 years, and she is now limited to swimming for her exercise. The client has a history of ovarian cyst, rotator cuff tear (repaired when in college), cluster headaches, rheumatic heart disease, and hypertension. She was then referred to Orthopedics for further management for severe left knee osteoarthritis. After imaging and a follow-up appointment, the client was offered a surgical option and was agreeable to total knee arthroplasty.

Vital signs: temperature 98.6°F (37°C), heart rate of 92 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 150/94, and pulse oximetry reading of 96%.

Monday 1500: Admission labs drawn. Client is anxious about procedure. Pain is reported as 6 on a 0-to-10 pain scale. Client is given 400 mg of ibuprofen orally.

Monday 1800: Foley catheter placed.

Monday 2000: Client was seen by anesthesia service.

Tuesday 0600: Client was sent to operating room with cap and gown.

Tuesday 1530: Client returned to room. She is lethargic and in pain but answering questions.

Tuesday 1800: Orthopedics team visited client and prescribed hydromorphone 1 mg IV push every 4 hours PRN pain, regular diet, and changed activity to non-weightbearing. Physical Medicine and Rehabilitation, Physical Therapy, and Occupational Therapy were consulted.

• NPO at midnight
• Ibuprofen 400 mg po every 6 hours
• Vital signs every 4 hours
• Foley catheter placement
• Transfer to operating room at 0600 with cap and gown

Left knee x-ray findings show severe degenerative changes with osteophyte complexes.

Rationale:

Risk factors for osteoarthritis include age over 40, obesity, female, and high level of sports activities. Additional risk factors include a family history of osteoarthritis, hypermobility syndromes, peripheral neuropathy, and an occupation requiring overuse of joints. Swimming is a low-impact activity that is safe for those with osteoarthritis and will not increase the risk. Ovarian cysts, rotator cuff tear, cluster headaches, rheumatic heart disease, and hypertension are not risk factors for osteoarthritis of the knee.

Musculoskeletal – Patient 3

An 82-year-old woman presents to the emergency department (ED) for new onset wrist pain. She notes that she was walking her small dog on a leash the evening before and heard a “popping sound” in her wrist when the dog tried to run away. She notes severe pain and swelling to the right wrist. She has a history of cerebrovascular accident, breast cancer (left mastectomy at age 57), urinary incontinence, hearing loss, arthritis, and coronary artery disease. She notes that she does not eat well and that she has lost weight and thinks that she is shorter.

Vital signs are temperature 98.6°F (37°C), heart rate of 106 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 98/72, and pulse oximetry reading of 97%.

• Regular diet
• Vital signs every 4 hours
• Aspirin 81 mg po daily
• Clopidogrel 75 mg po daily
• Atorvastatin 40 mg po nightly
• Acetaminophen 500 mg po every 6 hours PRN pain
• Orthopedics consultation

X-ray right hand reveals linear fracture to distal radius.

Rationale:

Potential Conditions Osteoporosis is a condition that typically affects postmenopausal women and is characterized by a decreased bone density that can lead to pathologic fractures. Osteoarthritis is a degenerative joint condition causing severe pain in one or more joints; this client has pain in one joint with an obvious history of trauma and acute onset. Septic arthritis is an infection of a joint and would present with an inflamed joint and leukocytosis. Rheumatoid arthritis is a disease affecting many joints that is typically worse in the morning and exhibits characteristic deformities of the hands and wrists. Relevant Cues Loss of height is seen in osteoporosis because of vertebral fractures. The radial fracture experienced in this client with minimal trauma (small dog) is consistent with osteoporosis. Her anemia is unrelated to osteoporosis. The tachycardia could be caused by the anemia or the pain from the fracture but is not specific to osteoporosis. Loss of weight does occur in older adults and is not related to osteoporosis. Risk Factors Cigarette smoking and nulliparity are risk factors for osteoporosis. Other risk factors include light body frame (thin), increasing age, family history of osteoporosis, previous fractures, amenorrhea or menopause before 45 years of age, postmenopausal, sedentary lifestyle, lack of aerobic or weight-bearing exercise, constant dieting, inadequate calcium and vitamin D intake, excessive carbonated soft drinks per day, scoliosis, rheumatoid arthritis, cancer, multiple sclerosis, chronic illness, previous fractures, metabolic disorders (e.g., diabetes, hypercortisolism, malabsorption, hypogonadism, hyperthyroidism), drugs that decrease bone density (e.g., thyroxine, corticosteroids, heparin, lithium, anticonvulsants, antacids with aluminum), and heavy alcohol use. Having an active lifestyle (weight bearing exercises, aerobics) can help reduce the risk of osteoporosis. Early, not late, menopause is a risk factor for osteoporosis. Skeletal changes that result in osteoporosis later in life are the result of poor vitamin and mineral intake early in life, while the skeleton is growing. Later life nutritional deficits are not a risk factor for osteoporosis.