Transcript Grandma`s aching knees and snapping fingers

Grandma’s aching knees and
snapping fingers
C1
LeeChuy, Katherine
Lee, Sidney Abert
Lerma, Daniel Joseph
Legaspi, Roberto Jose
Li, Henry Winston
Li, Kingbherly
Lichauco, Rafael
Lim, Imee Loren
Lim, Jason Morven
Lim, John Harold
Lim, Mary
Lim, Phoebe Ruth
Lim, Syndel Raina
Lipana, Kirk Andrew
Liu, Johanna
Llamas, Camilla Alay
79 y/o F
Chief Complaint
Chronic knee pain
Pain and stiffness of thumb and middle finger of
R hand
History of Present Illness
• Painful knees, more pronounced on walking
Years
Recently
• Limited kitchen and cooking chores
• Pain and stiffness of thumb and middle finger of
R hand
• Prescribed NSAID, temporary relief
Past Medical History
Hypertension
• Controlled on daily
amlodipine
Osteoporosis
• 2 yearly infusion of
zoledronic acid
Physical Examination
• Normal vital signs; BMI 28
Musculoskeletal Exam
• Crepitus on both knees without effusion
• 1st and 3rd fingers of R hand would snap on flexion
and required assistance due to pain on attempted
extension
Physical Examination
Stooped posture
Bilateral genu varum deformity
Non-tender bony nodes on PIP and DIP
Salient Features
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79 y/o female
Years of painful knees, pronounced when walking
Crepitus on both knees without effusion
Bilateral genu varum
Pain and stiffness of thumb and middle finger of R
hand
would snap on flexion and require assistance on
extension
Non-tender bony nodules on PIP and DIP
Diagnosed with osteoporosis, received 2 yearly
infusion of zoledronic acid
Stooped posture
Hypertension controlled on daily amlodipine
Musculoskeletal signs and
symptoms in the Patient
• Painful knees, more pronounced on walking; Nontender bony nodules on PIP and DIP; Crepitus on
both knees without effusion; bilateral genu varum
• Pain and stiffness of thumb and middle finger of R
hand; would snap on flexion and require assistance
on extension
• Stooped posture; previous diagnosis of osteoporosis
with prescribed medication
Musculoskeletal conditions in the
Patient
Osteoarthritis
Painful knees, more pronounced on walking; Non-tender
bony nodules on PIP and DIP; Crepitus on both knees without
effusion; bilateral genu varum
“Trigger Finger/ Digit”
Pain and stiffness of thumb and middle finger of R hand;
would snap on flexion and require assistance on extension
Osteoporosis
Stooped posture
Osteoarthritis
Patient
Osteoarthritis
79 years old female
leading cause of disability in the
elderly
BMI = 28
Obesity
Painful knees; Crepitus on both affected joints include the
knees without effusion
cervical and lumbosacral spine,
hip, knee.
Painful knee on walking
Joint pain from OA is activityrelated
Non-tender bony nodules on
Presence of Heberden’s nodes
PIP and DIP
in DIP and Bouchard’s nodes in
PIP
Management for OA
Non-pharmacologic Management
(1) avoiding activities that overload the joint, as evidenced by their
causing pain
(2) improving the strength and conditioning of muscles that bridge the
joint, so as to optimize their function
(3) unloading the joint, either by redistributing load within the joint with a
brace or a splint or by unloading the joint during weight bearing with a
cane or a crutch.
Management for OA
Exercise
lessens pain and improves physical function
consist of aerobic and/or resistance training (strengthens muscles
across the joints)
Management for OA
Correction of Malalignment
(Genu Varus/Valgus)
• Leg brace
• Surgery
Management for OA
“Trigger-finger/digit”
Patient
Trigger-finger
•Pain and stiffness
of thumb and
middle finger of R
hand
•would snap on
flexion and
require assistance
on extension
•common
disorder of later
adulthood
characterized by
catching,
snapping or
locking of the
involved finger
flexor tendon,
associated with
dysfunction and
pain
Management for “Trigger-finger/digit”
• Local steroid injection
– Cortisone, prednisolone, dexamethasone, and
triamcinolone.
– A mixture of steroid, 1% lidocaine, and 0.5%
bupivacaine is used, in a ratio of 2:1:1,
respectively
– After injection, the patient is encouraged to move
the digit.
– A follow-up appointment is made for 3-4 weeks
after the treatment
Management for “Trigger-finger/digit”
• Splinting
– For those patients who decline injection
– MCP joint is splinted in approximately 15° of
flexion.
Osteoporosis
Patient
Osteoporosis
79 y/o
Advanced age
Female
Female sex
Estrogen deficiency
Low calcium intake
Alcohol and cigarette
consumption
Management for Osteoporosis
To maintain bone health:
• Make sure there is enough calcium in your
diet
• Get adequate vitamin D intake, which is
important for calcium absorption and to
maintain muscle strength
• Get regular exercise, especially weight-bearing
exercise.
Management for Osteoporosis
• Bisphophonates
– alendronate, residronate, etidronate
– Patient was given zoledronic acid
• Calcitonin
– Calcitonin works by directly inhibiting osteoclast
activity via the calcitonin receptor.
– Calcitonin directly induces inhibition of
osteoclastic bone resorption by affecting actin
cytoskeleton which is needed for the osteoclastic
activity.
Management for Osteoporosis
• Selective Estrogen Receptor Modulators
(SERMs)
– are a class of medications that act on the estrogen
receptors throughout the body in a selective
manner
– Raloxifene (60 mg/d) - act on the bone by slowing
bone resorption by the osteoclasts
What is the mechanism of action
of NSAIDs?
NSAIDs
• Most NSAIDs act as nonselective inhibitors of
the enzyme cyclooxygenase(COX), inhibiting
both the cyclooxygenase-1 (COX-1) and
cyclooxygenase-2 (COX-2) isoenzymes.
• COX catalyzes the formation of prostaglandins
and thromboxane from arachidonic acid
• Prostaglandins act as messenger molecules in
the process of inflammation.
MOA of NSAIDS
Selective and Non-Selective NSAID
Stomach
Macrophages
Kidney
Leukocytes
Platelets
Fibroblasts
Endotheliumcc
Endothelium
Bisphosphonate preparations
Philippine
Brands
Primary
indication
Dose
Route
Alendronate
Fosamax
Osteoporosis
10 mg/day;
70mg/week
Oral
Risedronate
Actonel
Osteoporosis
5 mg/day; 35
mg/week
Oral
Ibandronate
Bondronat,
Bonviva
Osteoporosis
2.5 mg/day;
150mg/month
Oral
Pamidronate
Aredia
Bone
Metastasis
90mg/3 weeks
IV
Zoledronate
Aclasta,
Zometa
Bone
Metastasis
4mg/3 weeks
IV
Incadronate
Bisphonal
Bone
metastasis
10mg/2weeks
IV
Clodronate
Bonefos
Pagets / Bone
metastasis
1600-3200md/day
Oral
300mg/day
IV
Thank You!