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Musculoskeletal Disorders Case Study 32 Osteoporosis Difficulty: Beginning Setting: Outpatient clinic Index Words: osteoporosis, risk factors, treatment, medications

X Scenario M.S., a 72-year-old white woman, comes to your clinic for a complete physical examination. She has not been to a provider for 11 years because “I don't like doctors.” Her only complaint today is “pain in my upper back.” She describes the pain as sharp and knifelike. The pain began approximately 3 weeks ago when she was getting out of bed in the morning and hasn't changed at all. M.S. rates her pain as 6 on a 0- to 10-point pain scale and says the pain decreases to 3 or 4 after taking “a couple of ibuprofen.” She denies recent falls or trauma. M.S. admits she needs to quit smoking and start exercising but states, “I don't have the energy to exercise, and besides, I've always been thin.” She has smoked one to two packs of cigarettes per day since she was 17 years old. Her last blood work was 11 years ago, and she can't remember the results. She went through menopause at the age of 47 and has never taken hormone replacement therapy. The physical exam was unremarkable other than moderate tenderness to deep palpation over the spinous process at T7. No masses or tenderness to the tissue surrounded the tender spot. No visible masses, skin changes, or erythema were noted. Her neurologic exam is intact, and no muscle wasting is noted.

1. An x-ray examination of the thoracic spine reveals osteopenic changes at T7. What does this result mean? Osteopenia is decreased bone density. Osteoporosis is decreased bone density at a level that can be diagnosed by conventional x-rays. Bone loss is not detected by conventional x-rays until bone loss is in the 25% to 45% range. In this case, the patient reports pain in the area at the bottom of her shoulder blades; however, lower back pain is also a frequent early symptom of osteoporosis.

2. The physician suspects osteoporosis. List seven risk factors associated with osteoporosis. The risk factors for osteoporosis are: • Cigarette smoking • Female gender • White or Asian race • Lack of adequate exercise • Lifelong insufficient calcium and vitamin D intake • Low body weight (less than 128 pounds) • Postmenopausal status (estrogen deficiency) • Alcoholism • History of fractures in a first-degree relative • Advanced age (65 years and older in women; over age 75 in men) • Long term of specific medications that can lead to loss of bone density, such as glucocorticoids and i i il i d

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3. Place a star or asterisk next to those risk factors specific to M.S. Cigarette smoking, female gender, low body weight, white or Asian race, lack of adequate exercise, postmenopausal status, advanced age

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CASE STUDY PROGRESS M.S. has never had an osteoporosis screening. She confides that her mother and grandmother were diagnosed with osteoporosis when they were in their early 50s.

4. What diagnostic test is most commonly used to diagnose osteoporosis? The dual-energy x-ray absorptiometry (DEXA) scan. The DEXA scan is a precise test that emits less radiation than even a chest x-ray and is considered the best tool currently available for the diagnosis of osteoporosis. Other tests include the quantitative computed tomography, which is much more expensive than the DEXA, and quantitative ultrasound of the heel.

5. M.S.'s diagnostic test revealed a bone density T-score of –2.7. How will this be interpreted? The T-score is a calculated result of the DEXA scan that assesses the patient's bone mineral density (BMD). Normal results would be less than 1 standard deviation below normal (>–1). Osteopenia is 1 to 2.5 standard deviations below normal, or –1 to –2.5. Osteoporosis is greater than 2.5 standard deviations below normal. M.S.'s T-score of –2.7 standard deviations below normal is defined as osteoporosis and associated with an increased risk of skeletal fracture. For a T-score below –1.5, in a patient with risk factors or a history of previous fractures, drug therapy for osteoporosis is recommended.

6. M.S. receives a prescription for alendronate (Fosamax) 70 mg/week. Which instructions are appropriate as you provide patient teaching to M.S. about this drug? (Select all that apply.) a. “Take the medication with 8 ounces of water immediately upon arising.” b. “You can take this medication with your morning coffee or orange juice.” c. “You can eat your breakfast along with this medication.” d. “You need to sit or stand upright for at least 30 minutes after taking the medication.” e. “If you experience any severe abdominal pain, vomiting, or jaw pain, notify your doctor immediately.” Answers: A, D, E Take the medication exactly as prescribed: Take the medication first thing in the morning; take it with at least 8 ounces of plain water. Mineral water, orange juice, caffeine, and other liquids decrease absorption of the medication. Allow at least 30 minutes before eating or drinking anything else to improve absorption of the medication. She needs to remain upright (sit or stand) for at least 30 minutes after taking the medication. Bending or reclining increases the risk of esophageal reflux of the medication, causing irritation. Abdominal pain, nausea, vomiting, and jaw pain are symptoms of possible severe side effects and should be reported immediately.

7. M.S. is also instructed to take a calcium plus vitamin D supplement. She asks, “If I am taking the osteoporosis pill, won't that be enough?” How do you answer her? Explain to her that a calcium supplement, such as calcium citrate or calcium carbonate, along with the vitamin D, are essential in order to provide the “materials” needed for the alendronate to build bone and promote bone healing.

8. What nonpharmacologic interventions will you teach M.S. to prevent further bone loss? Smoking cessation: Smoking is known to accelerate bone loss and increase the metabolism of medications. Smoking cessation methods include gum, patches, hypnosis, and support groups. Some patients fail many times before becoming successful at stopping smoking She should not

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Exercise : Regular weight-bearing exercise decreases calcium loss from bones (swimming does not qualify). Exercise for 30 minutes at least three times a week. Start slowly and increase gradually. Walking is excellent. It is important to get enough weight-bearing exercise (at least 30 minutes on most days). If your feet touch the ground during exercise, it is considered weight-bearing. Running and walking are weight-bearing; swimming and biking are not. Low-impact aerobic movement or dancing is also effective. It is important for the exercise to be enjoyable to increase the likelihood of long-term compliance because the benefit of exercise is quickly lost once the individual stops exercising. Diet: Adequate protein, calcium, and vitamin D are essential to bone health. Dietary sources of calcium include milk, cottage cheese, yogurt, hard cheeses, and dark green vegetables such as broccoli or spinach. If taking supplemental calcium, the patient should take it with meals to ensure optimal absorption. M.S. should be referred to a registered dietitian for dietary analysis and recommendations for a nutritional plan that emphasizes vegetables, fruits, and low-fat dairy and protein sources. In addition, she needs to reduce her intake of caffeine.

CASE STUDY PROGRESS M.S. seems overwhelmed and says, “I cannot possibly stop smoking and lose weight and exercise all at the same time.”

9. You encourage M.S. to start working on one problem at a time. Which problem should M.S. attempt first? Let her choose the problem. She is more likely to be successful if she works on the problem that she feels most capable of resolving.

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Case Study 33 Low Back Pain Difficulty: Beginning Setting: Hospital emergency department, home Index Words: low back strain, rehabilitation, medications, risk factors

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Scenario

J.C. is a 41-year-old man who comes to the emergency department with complaints of acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a “10” on a 1 to 10 scale. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” J.C. has a past medical history of peptic ulcer disease (PUD) related to nonsteroidal anti-inflammatory drug (NSAID) use. He is 6 feet tall, weighs 265 pounds, and has a prominent “potbelly.”

1. What questions would be appropriate to ask J.C. in evaluating the extent of his back pain and injury? Obtain a clear chronologic narrative of problem onset, setting, manifestation, and past medical treatment. Principal symptoms should be described. Use the COLDERRA mnemonic to guide questions. (COLDERRA: Characteristics, Onset, Location, Duration, Exacerbation, Radiation, Relief, Associated S/S)

2. What observable characteristic does J.C. have that makes him highly susceptible to low back injury? His potbelly puts undue strain on the lumbar joints, muscles, and tendons in his low back.

3. J.C. used to take piroxicam (Feldene) 20 mg until he developed his duodenal ulcer. What is the relationship between the two? What signs and symptoms would you expect if an ulcer developed? Piroxicam, like other NSAIDs, can precipitate peptic ulceration and GI bleeding, especially if taken on an empty stomach. S/S of GI bleeding would include abdominal pain or other GI discomfort, tarry, maroon-colored, or bloody stools.

CASE STUDY PROGRESS All serious medical conditions are ruled out, and J.C. is diagnosed with lumbar strain. The nurse practitioner (NP) orders a physical therapy consult to develop a home stretching and back-strengthening exercise program and a dietary consult for weight reduction. J.C. is given prescriptions for cyclobenzaprine (Flexeril) 10 mg tid × 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months. He receives the following instructions: heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds. J.C. is instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles. He is given a written excuse to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds for 3 months. He is instructed to contact his primary care provider if the pain gets worse.

4. J.C. looks at the prescription for cyclobenzaprine (Flexeril) and states, “I'm glad you didn't give me that Valium. They gave me Valium last time and that stuff knocked me out.” How would you respond to J.C.? The skeletal muscle relaxant, cyclobenzaprine, might also cause extreme drowsiness, as well as di i d bl d i i H d h ii l l id h i h i

PART 1 MEDICALSURGICAL CASES General instructions also include to avoid driving or using sharp objects until the response to the drug is known, but he is to stay off work for 5 days and in bed for the first 1 to 2 days.

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5. Why do you think that cyclobenzaprine was prescribed instead of diazepam (Valium)? • Cyclobenzaprine is a centrally acting skeletal muscle relaxant. There is no evidence that muscle relaxants help when used more than 1 week. • Diazepam is a sedative hypnotic, anticonvulsant, and muscle relaxant. It is a schedule IV drug because of the risk for abuse.

6. J.C. states, “Well, I'm glad I'll still be able to take my sleeping pill.” True or False? Explain. False! You need to remind him that skeletal muscle relaxants, such as Flexeril, cannot be taken with other central nervous system (CNS) depressants such as sleeping pills (hypnotics), sedatives, or alcohol, because increased CNS depression and mental confusion might result.

CASE STUDY PROGRESS J.C. asks, “What is Celebrex? I hope it won't do what that Feldene did to me years ago.”

7. Why do you think it was prescribed for J.C., considering his GI history? It was prescribed to reduce the chronic inflammatory processes causing his back pain. Celecoxib (Celebrex) is a COX-2 inhibitor that selectively inhibits prostaglandins responsible for joint pain. It is a newer member of the NSAIDs and has fewer GI adverse effects in comparison with older NSAIDs because of its COX-2 selectivity. However, GI toxicity is still a possibility, and, especially with his history, he needs to be very careful to watch for GI bleeding.

8. You know that it has been over 5 years since his last episode of GI bleeding. Are there any other conditions that you need to assess for before J.C. begins to take the celecoxib? Explain. The FDA has issued a Black Box Warning for all NSAIDs. This warning includes information that patients with cardiovascular disease or risk factors for cardiovascular disease might be at greater risk for serious cardiovascular events such as thrombotic events, MI, and stroke. J.C.'s cardiovascular status and risk factors need to be assessed closely.

9. Why would the NP prescribe an NSAID rather than acetaminophen for J.C.'s pain? Although it is frequently used for chronic joint pain, acetaminophen is an analgesic and antipyretic but lacks anti-inflammatory properties and does not stop the damage caused by chronic inflammatory processes.

10. A physical therapist teaches J.C. maintenance exercises he can do on his own to promote back health. Identify two common exercises that would be included. Single knee-to-chest: Lie on the back with knees bent at 90-degree angle and feet flat on the floor. Clasp hands behind one knee at a time and gently pull toward chest; hold 5 to 10 seconds. Alternate knees. Complete 6 to 10 repetitions at least twice a day. This can also be done from a seated position; as you lean forward, extend your arms and touch the floor. Abdominal curl: Lie on the back with knees flexed and feet flat on the floor, with arms extended beside knees. Inhale deeply. Tuck chin and exhale while slowly lifting shoulders from the floor. Hold position for 5 seconds, continuing to exhale and inhale while slowly returning to resting position. Pelvic tilt: Lie on the back with knees flexed and feet flat on the floor. Inhale deeply. Exhale slowly as you tighten buttocks and abdomen, pressing back into floor and tilting your pelvis toward the ceiling. Hold for 5 to 10 seconds while exhaling, then relax. Complete 6 to 10 repetitions at least twice a day. Hamstring stretch: Sit with one leg extended on the bed and the other leg off the side of the bed. Bend forward, reaching the hands toward the foot of the extended leg, and hold 10 to 30 seconds, then

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CASE STUDY 34

Case Study 34 Ankle Sprain Difficulty: Beginning Setting: Hospital emergency department Index Words: trauma, sprained ankle, substance abuse, assessment, medications

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Scenario

D.M., a 25-year-old man, hops into the emergency department (ED) with complaints of right ankle pain. He states that he was playing basketball and stepped on another player's foot, inverting his ankle. You note swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals, and pedal pulses are 3+ bilaterally. His vital signs are 124/76, 82, 18. He has no allergies and takes no medication. He states he has had no prior surgeries or medical problems.

1. When assessing D.M.'s injured ankle, what should be evaluated? Pulses, pain (at rest or with movement), paresthesia, paralysis, pallor. Note swelling, discoloration (bruising), range of motion.

2. What will initial management of the ankle involve to prevent further swelling and injury? The ankle will be immobilized with the leg elevated above the patient's heart. Ice bags should be applied to the ankle, and elastic wrap should be used to apply mild compression. (RICE: Rest, Ice, Compression, Elevation)

3. You note significant swelling over the fourth and fifth metatarsals. How would you further evaluate this finding? Apply pressure over the area to assess for pain. If pain is present, x-ray films should include the ankle as well as the foot. Inversion injuries commonly result in fracture of the fifth metatarsal.

CASE STUDY PROGRESS X-ray results are negative for fracture, and a second-degree sprain is diagnosed. The physician orders immobilization with an elastic bandage and an air stirrup brace, with instructions for crutches. The physician instructs D.M. not to bear weight on his ankle for 2 days, then to use only partial weight-bearing until the ankle heals.

4. Describe the technique for applying an elastic wrap. Give the rationale. The elastic wrapping should begin distally to prevent milking of venous blood flow and extravascular fluid downward. The wrap should be unrolled with little tension and should be smooth and without wrinkles. A figure-8 wrap should be used at the ankle joint. Capillary refill should be checked after application as well as checking the skin over the toes for warmth; observe skin color for pallor.

5. When instructing D.M. to use crutches, D.M. states that he “likes it better” when the crutches rest under his arms while walking with the crutches. Is this correct? Explain. He needs to bear his weight on his hands, wrists, and arms. The axillary area should never be used to support the weight; this can result in nerve damage. The top of the crutches should be two finger widths below the axilla. Arms should be kept straight with hands on the grips. Place crutches far enough apart to allow the body to swing through unimpeded.

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6. You instruct D.M. on using the three-point gait with the crutches. Which would be the correct first step for the three-point gait? a. Step first with the affected leg. b. Step first with the unaffected leg. c. Step first with both crutches and the affected leg. d. Step first with the affected leg and the crutch opposite of the affected leg. Answer: B Three-point gait requires the patient to bear all weight on one foot and is useful for patients with a broken leg or sprained ankle. The weight is born on the unaffected leg and then on both crutches. No weight is placed on the affected leg.

7. You are to instruct D.M. on application of cold, activity, and care of the ankle. What would be appropriate instructions in these areas? • Do not bear weight on the affected ankle for 48 hours. Use crutches for walking. • Keep the affected ankle elevated on pillows (above the heart) as much as possible for 48 hours. • Apply an ice bag to the ankle for 20 minutes out of every hour while awake for the first 24 to 48 hours.

8. D.M. is given a prescription for Lortab 2.5/500. Explain the meaning of the numbers. Lortab is a combination of hydrocodone (an opioid analgesic) and acetaminophen (a non-opioid analgesic). The numbers refer to the amount of each drug per tablet. Each tablet contains 2.5 mg of hydrocodone and 500 mg of acetaminophen.

9. What instructions concerning the Lortab are needed? • Take this medication with food (at mealtimes or with crackers and a glass of milk). • Do not combine this drug with other medications or OTC drugs without first checking with a pharmacist. Lortab should never be taken with alcohol. He should not drive or operate heavy machinery after taking the medication. • Patients with a history of heavy alcohol consumption should be warned against using medications containing acetaminophen. • Lortab contains hydrocodone, which is constipating. The patient needs to increase fiber and liquid in...