Assignment: reduce the barriers that hinder healthcare literacy

“My hand and knee joints have been stiff and painful in the morning hours and when am performing my house chores and this is really limiting my daily activities.”

The patient reports that she started experiencing mild hand joint pain three years ago which aggravated when she was working. The pain progressed over time and also started manifesting on her knee joints. The pain advanced from mild to moderate and six months ago she started experiencing joint stiffness when walking, working and in the morning. In the past month, she reports that she experiences stiffness even during rest.

She describes the pain as deep and achy and it is experienced in her finger joints and both knee joints lasting for about 10 minutes. The symptoms began three years ago and are aggravated by activity. Pain is relieved to some degree by rest and Tylenol but the stiffness is not relieved by rest. She denies using any other medication or measures to relieve the symptoms.

Tylenol to relieve joint pain.

Allergies:

No known food or drug allergies.

Medication Intolerances:

No drug intolerance

Chronic Illnesses/Major traumas

No history of chronic diseases. Had a tibia fracture at 38 years from an RTA.

Hospitalizations/Surgeries

Was hospitalized at 38 years after sustaining a tibia fracture from an RTA. Had a surgery on her left leg to repair a tibia fracture.

She is the 3^rd born in a family of 4. Mother had DM, died at 82 from renal failure. Father died at 86 from unknown causes. One elder sibling has Colon cancer, other siblings alive and well. No history of arthritis and psychiatric illnesses in the family.

She is a retired midwife and currently lives with her husband in their ranch. She has two children. Denies tobacco, marijuana and alcohol use. Reports having minimal physical activity and exercises.

Limited ability to perform activities; Weight gain.

Denies chest pain, heart palpitations, SOB or edema

Denies skin discoloration, rashes, bruises, lesions or bleeding.

Denies cough, wheezing, SOB, and hemoptysis. No history of TB.

Denies blurred or double vision and decline in vision.

Denies abdominal pain, epigastric pain, nausea, vomiting, diarrhea, constipation, eating disorders, and black stools.

Denies ear pain, discharge, hearing loss, and ringing in ears.

Denies urinary urgency, increased frequency, and pain during urination and change in color of urine.

Menopause at 48 years. Denies being sexually active. Last pap smear 2 years ago. Denies abnormal vaginal discharge.

Denies mucous discharge and nose bleeding.

Denies dental pain, tooth cavities, difficulty in swallowing and voice hoarseness.

Reports low back pain, hand and knee joint pain and stiffness.

History of tibia fracture.

Denies muscle pain and history of osteoporosis.

Denies breast changes, nipple discharge and breast lumps or masses.

Reports tingling sensations on the toes.

Denies seizures, fainting, muscle weakness and headaches.

HIV- NR.

No history of blood transfusion.

Denies history of blood loss, excessive sweating, acute thirst, excessive hunger and heat or cold intolerance.

Denies history of depression, sleeping difficulties, anxiety disorder, and suicidal thoughts or attempts.

Patient in no distress. Has an abnormal gait and posture. Appropriately dressed and well-groomed. Alert and oriented to person, place and time.

Skin is fair, clean, warm and dry. No rashes, bruises, and lesions.

Head is symmetrical, normocephalic, and atraumatic. Hair blonde and evenly distributed. Eyes: sclera is white, PERRLA. EOMs intact. No inflammation of the conjunctiva and sclera. Ears: Mastoid bone non-inflamed; Ear canals patent, ear wax present; tympanic membrane intact. Nose: Nasal septum well-aligned; Nasal mucosa pink. Mouth: Oral mucosa is pink and moist. Pharynx and Tonsillar gland non-inflamed. 3 teeth missing, no tooth cavities noted. No halitosis.

Neck: Symmetrical; Full ROM; non-palpable cervical and occipital lymph nodes. Thyroid gland normal.

No JVD and edema. HR 86. S1, and S2 present with regular rhythm. No S gallop, heart murmurs, rubs, and bruits. Capillary refill time 3seconds

No chest wall deformity noted. Chest rise and falls in unison during breathing in and out. No use of accessory muscles. On auscultation, the lungs are clear. Breath sounds audible. No wheeze, rhonchi, grunting or crackles present.

Abdomen is round, and smooth. No abdominal scars noted. Bowel sounds active in all quadrants. On palpation, no tenderness, no abdominal masses, no hepatomegaly and splenomegaly.

No breast skin discoloration or dimpling. On palpation, no tenderness, masses or lumps noted.

On palpation, urinary bladder is non-distended. Skin over the mon pubis is clear with normal hair distribution. Urethral opening is slit-like in appearance & midline; it is free of discharge, swelling or redness. Vaginal introitus mucosa is pink and moist. Clear vaginal discharge present with no foul odor. Vagina is patent with no bulging.

Rectum has a good sphincter tone at rest and when bearing down. No pain, tenderness, irregularities or nodules in the rectum and rectal wall.

Muscle strength at 4/5.

Reduced ROM of interphalangeal and knee joints with crepitus. Nodes present in the distal interphalangeal joints. On palpation, interphalangeal joints are tender and enlarged. Joints warm on touch. Bending posture.

Stable balance. Abnormal gait. Speech is clear.

Appropriately dressed and well groomed. Alert and oriented x 3. Responds to questions appropriately. No suicidal thoughts or ideas. No hallucinations, illusions or delusions noted. No pressure of speech, flight of ideas or thought blocking. Good abstract thought, judgment, memory and has insight.

C-reactive protein (CRP)- 2.0 mg/L

WBC count- 1000/uL

Rheumatoid factor-Negative

X-ray of knee joint and interphalangeal joints- Reveals narrowing of joint space and osteophytes.

Rheumatoid Arthritis: Is characterized with prominent and prolonged morning stiffness lasting for more than an hour. The affected joints are usually warm, swollen, and tender, deformed, and have nodules with limited motion (Firestein & McInnes, 2017). Radiography findings in rheumatoid arthritis reveal marginal or periarticular bone erosion rather than bone formation. Besides, WBC, ESR, and CRP levels are elevated, and rheumatoid factor is mostly positive in patients having rheumatoid arthritis (Firestein & McInnes, 2017). Rheumatoid arthritis is a likely diagnosis based on the history of morning joint stiffness, pain as well as findings of tender, warm, and nodes on joints. However, normal levels of ESR, CRP, and a negative rheumatoid factor rules out rheumatoid as a final diagnosis.

Gout: Gout manifests with excruciating pain, edema, and inflammation of joints, and the most affected joint is the big toe metatarsal phalangeal joint (Qaseem, McLean, Starkey & Forciea, 2017). It also affects finger, wrist, knee and ankle joints, and on gout attacks, they are often red, hot, and tender on palpation. Gout is a probable diagnosis as per symptoms of joint pain and positive findings of nodes on the interphalangeal joints.

Psoriatic arthritis: This is a condition that is mostly preceded by psoriasis and is characterized by joint stiffness and pain (Ritchlin, Colbert & Gladman, 2017). Patients with psoriatic arthritis also present with heel pain, high levels of fatigue, and worsening of symptoms with physical function. Besides, on physical examination, there is minimal joint tenderness, inflammation of an entire digit, and the patient has sausage-like digits (Ritchlin, Colbert & Gladman, 2017). Psoriatic arthritis is a likely diagnosis as per symptoms of joint pain and stiffness and physical exam findings of joint tenderness and warmth on touch.

Final Diagnosis

Osteoarthritis: This is a degenerative disorder that results from the breakdown of articular cartilage in synovial joints (Loeser, Collins & Diekman, 2016). The classic symptom of osteoarthritis is deep joint pain that is exacerbated by extensive joint use (Glyn-Jones et al., 2015). The condition also presents with reduced range of motion in affected joints and joint stiffness during rest. Morning joint stiffness occurs and lasts for not more than 30 minutes. In osteoarthritis of the hand, distal interphalangeal joints are the most affected and have Heberden nodes which represent osteophytes in the joints (Loeser, Collins & Diekman, 2016). Levels of inflammatory biomarkers such as ESR, CRP, and WBC are usually within the normal range. Radiography of joints reveals narrowed joint space due to loss of cartilage (Glyn-Jones et al., 2015). Osteoarthritis is the most probable diagnosis as per the patient’s history of joint pain, morning stiffness, and at rest as well as limited activity. Physical findings of a limited range of motion, joint enlargement, and joint nodes also make it a highly likely diagnosis. Besides, joint radiography revealing narrowing of joint space and osteophytes and non-elevated levels of ESR, WBC, and CRP makes it the possible final diagnosis.

Plan

Further Diagnostic Tests: Arthrocentesis within 12 hours to exclude joint infection and inflammatory arthritis.

Medication:

1.     Meloxicam- 7.5 mg PO OD for 2 weeks; to alleviate joint pain.

2.     Topical Capsaicin- 0.075% TDS for 6 weeks; to decrease pain perception.

Non-pharmacological Therapy:

Occupational therapy on joint protection techniques and physical therapy techniques to help the patient perform her activities of daily living (Glyn-Jones et al., 2015).

Health Education

Regular exercises to facilitate weight reduction and reduce stress on the affected knee joint. Reduction of stress on knee joints slows down the loss of cartilage in the joints (Glyn-Jones et al., 2015).

Nutrition counseling: the patient will be advised to take a healthy diet with low caloric content to help in reducing weight, decrease the load on the joints, and increase joint mobilization.

Heat and cold applications to alleviate joint stiffness and pain.

Follow-up: The patient will be scheduled for a follow-up appointment after 4 weeks for evaluation of progress and monitoring of complications. She will be advised to seek emergency medical attention in case her symptoms become severe.