Osteoporosis Case Scenario - Essay Example

"Osteoporosis Case Scenario" is a great example of a paper on symptoms.
Patient ID: Mrs R

Source: All the information is collected from the patient who seems to be in a stable mental status, therefore, reliable.

Chief complaint: Hip pain and irregular menses

History of Present Illness: Mrs R a 45-year-old white female presents to the health clinic with a past medical history that was normal and presents today complaining of sharp hip pain that began while playing tennis. The patient has persisted for one week and has developed a limp because of the continuous hip pain. She has used over-the-counter medication non-steroidal anti-inflammatory medicine Motrin. The medicine has not been effective that is why she has sought medical advice. The pain is found on the inside of the hip joint and does not extend. The pain is continuous throughout the day and night but varies in severity. Mrs R rates the pain at the score of 7/10 at its worst. According to the patient, the pain is ‘sharp’ and is not relieved by rest of the drugs. The pain increases when playing tennis, but also experiences the pain performing other activities like walking. She experiences irregular menses and has notably hot flashes and other postmenopausal signs. The patient takes one multivitamin tablet a day.

Past medical history: no known illness.

Hospitalizations: none

Surgeries/procedures: none

Medications: 1200mg calcium citrate and 800IU vitamin D qd two years ago, 1.3 mg vitamin B6

Allergies: no known drug allergies

Family history:  The mother suffers from Breast Cancer. Medical history of the father is not known

Social and substance use history: Mrs R is an active tennis player. She is married and has two children. She denies having engaged in alcohol, illegal drug, and tobacco use. She is covered by Medicare.

Physical examination: She is well nourished and developed. The right hip assessment discloses no obvious deformity. The log roll is negative. T.R. is capable of generating a palpable pop by abducting and flexing the hip. The hip range tests of motion are:

-    Internal and external rotation equal and full bilaterally.

-    Flexion: full bilaterally

-    Extension: 15o bilaterally

-    Adduction and abduction: full and equal bilaterally

Laboratory tests: none collected

Differential diagnosis: DXA tests to check the bone density.

Diagnostic studies: the T-score is -2.2 that confirms osteoporosis

Pharmacological intervention: Start hormone-replacement therapy with Premarin plus Provera (Davies, 2008). 5mg per day prednisone for three months, 600mg Ibuprofen three times a day.

Non-pharmacologic intervention: the patient will be educated on the correct diet with sufficient calcium and vitamin D intake (Phelps & Hassed, 2010). In addition, she was advised on the appropriate physical activities.

Patient education: the significance of the DXA scan was deliberated with the patient. In addition, the patient was counselled on the risk of low T-score in menopause.

Referrals: If osteoporosis is revealed through the T-score, refer Mrs R to an orthopedist

Follow-up plan: The patient is advised to report back to the clinic after three months.