Case Study Three
CC: Jose Santa Cruz (JS) is a 68 y/o Native American male and retired construction worker. JS no longer works at this time, except to watch his grandchildren occasionally.
ID: 68 y/o Native American Male, retired construction worker.
CC: Rt knee pain x many years; epigastric burning with food x 2 weeks with dark stools.
HPI: Pt c/o previous history rt knee pain for many years. He also c/o epigastric burning over past 2 weeks, and newly noted dark stools with no other prior history. Onset of rt knee pain approximately 7-8 years ago and increasing at this time. Epigastric burning onset is described as 2 weeks ago with dark stools noticed over past couple days. The location of his knee pain is centered over knee joint. Epigastric pain is focused in the mid to rt upper abd per Pt. Characteristics of his rt knee pain include occasional sharpness with an ongoing ache. His epigastric pain is characterized as burning which occasionally wakes him at night. He describes his stools over the past 1-2 days as dark-black in color, but not tarry in texture. JS denotes aggravating knee pain with movement especially getting up and down, or any activities which put pressure on his knee. He states his epigastric burning is aggravated by certain foods, especially high spice foods. His stools are recently dark- no aggravating of the color change noted. Relief of rt knee pain has been attempted with Advil 800mg po tid without good pain control. JS has also tried Tylenol 1gm po qid without relief acheieved. JS states his epigastric pain was relieved with certain foods. He also tried Tums otc without any noted relief. JS does not note any relief of dark stools as they have only started recently. JS does not c/o a specific time to his knee pain. He states it is always there, but worse when aggravated. He does note his epigastric pain is worse after eating certain foods. He is not aware of any time specific to his dark stools. He describes the severity of his knee pain as affecting his life- making it hard to play with his grandchildren. He also describes the severity of his epigastric pain as interfering with sleep due to the burning sensation. He is unable to describe a severity to his dark stools.
Epigastric pain relieved with food. Pt tried Tums OTC w/o relief. Meds: Advil 800mg PO TID; history of Tylenol use 1gm QID- no longer using; Tums 2 tablets 3-4 times per day currently used without relief.
PMH: See HPI, otherwise negative.
PSH: Negative.
Family History: Non contributory.
Social History: Negative for smoking or drinking; negative for caffeine use. Pt states he is LDS and does not believe in participating in these activities.
ROS:
Gen: Denies change in appetite, fatigue, weakness, fever, chills, night sweats, polydipsia, and syncope.
Pulm: Denies cough, sputum production, hemoptysis, dyspnea, or wheezes.
CV: Denies chest pain, murmur, clubbing, cyanosis, edema, palpitations, orthostasis, orthopnea, or claudication.
GI: See HPI- denies change in appetite, dysphagia, n/v, constipation, hematemesis, hematochezia, melena, or jaundice.
MS: See HPI, denies previous history of arthritis, tenderness to touch, or gout history.

Vitals: 130/86 BP, 90 HR, 16 R, 98.2 T
Ht/Wt: BMI 29 (Ht 70 inches/ 5 ft 10 inches; 202lbs.)
General: Pt presents as well developed, no acute distress, alert/ oriented x 3 male.
Pulmonary: Lungs clear to auscultation, even and symmetrical.
Cardiac: S1, S2 auscultation, no clicks, rubs, or murmurs heard.
GI: Abdomen round, soft, bowel sounds auscultated, no bruits noted, liver border palpated wnl, unable to palpate spleen or kidneys at this time. No masses noted. MS: Rt knee joint range of motion and mobility limited to 80 degree flexion due to pain. Unable to hyperextend. Negative for swelling or erythema. Positive crepitus with ROM. Negative ballottement test. Mc Murray test neg, valgus and vargus neg, and anterior drawer test negative. Other joints and muscles are wnl without tenderness, effusion, erythema, or deformity.
Labs: Guiac negative for stool check in office; CBC Hb 10, Hct 30, RBC 3.0, MCV 70,
MCH 22, MCHC 28%, RDW 18, WBC 7,200, platelets 240,000. Differentials Unsupported information
Meniscus injury Mc Murray test negative, no history of injury.
ACL or PCL tear Negative drawer test, vargus and valgus test negative. No history of injury.
Acute GI bleed Stool negative, negative for vomiting blood. Low H&H could be explained by gastritis.
Rheumatoid Arthritis Unilateral single joint involvement.
H pylori Waiting for stool antigen.
Gout Uric acid level WNL.
Crohns Disease of esophagus Endoscopy needed for Dx. No history of diarrhea.
Achalasia Barium swallow to reveal loss of peristalsis. Denies backward regurgitation of food.
GERD No history of GERD before NSAID use.

Diagnosis Supported information
715.26 Primary osteoarthritis knee Unilateral knee pain, worse in the morning. Joint positive for decreased ROM and crepitus.
285. 0 Anemia Hemoglobin and hematocrit low. History of NSAID use.
535.5 Gastritis Burning Epigastric pain with a history of NSAID use. Abnormal H&H can be related to microscopic bleeding.
278.02 Overweight BMI of 25.0-29.0 is indicated as overweight indicating increased risk factors for diabetes, heart disease, and hypertension. ("Aim For A Healthy Weight", 2011).

V. Plan
Plan Rationale and EBP/supporting documentation
Vimovo 375/20 mg PO 1 tablet BID

Stop Advil Used to treat osteoarthritis; Naproxen is a NSAID that is slowly released and not for acute pain; Esomeprazole is a (PPI) proton pump inhibitor that is first line treatment for gastritis (Webmd, 2011).
Acetaminophen 325-1000 mg po q 4-5 hours as needed for pain, maximum 4000 mg/ day Acetaminophen with local analgesia indicated as second line treatment s/p failure of NSAIDs alone with pain ("Osteoarthritis", 2011), (Arthritis Foundation, 2011).
Tramadol 25 mg PO Q AM and then increase to 25 mg TID after 3 days PRN for severe pain. Analgesics relieve the pain of arthritis without the side effects of anti-inflammatory drugs and are recommended for moderate pain (Arthritis Foundation, 2011).
Capsaicin Topical 0.075% - apply to affected areas 3-4 times per day as needed. “First line treatment for Osteoarthritis includes local analgesia and various nonpharmacologic approaches” ("Osteoarthritis", 2011), (Arthritis Foundation, 2011).
Physical therapy referral for evaluation and treatment. Physical Therapy referral for exercises to strengthen knee, evaluate for possible knee brace, correct footwear, possible need for patellar bracing or taping” ("Osteoarthritis", 2011), (Arthritis Foundation, 2011).
Glucosamine 500mg po tid
Chrondroitin Sulfate 400mg po tid “Reduction in pain: there is moderate-quality evidence that glucosamine reduces pain compared with NSAIDs in people with OA of the knee; however, there was poor-quality evidence that glucosamine reduces pain compared with placebo.”
("National Center For Complementary And Alternative Medicine: Osteoarthritis", 2011), (Arthritis Foundation, 2011).
Accupuncture “A landmark study has shown that acupuncture provides pain relief and improves function for people with osteoarthritis of the knee and serves as an effective complement to standard care” ("National Center For Complementary And Alternative Medicine: Acupuncture", 2011).
Lifestyle modification r/t Overweight Reduce body weight by 10 percent; physical activity as tolerated such as swimming, walking; Reduce dietary fat and carbohydrates. Focus diet on healthy proteins, vegetables, and fruits.
Stool antigen for H pylori, stool for occult blood X 2, repeat CBC in 1 week. UGI series. Need to rule out h pylori infection, and acute GI bleed, and ulcer disease (U. S. Department of Health and Human Services, 2011).

Tdap, Herpes zoster vaccines Age appropriate screening and coverage (U.S. Preventitive services task force, 2007).
Follow-up in office and CBC w/dif, CMP prior to visit for review in 1 week Needed to evaluate the patient’s GI symptoms and any abnormal lab and trends for unexplained blood loss. GI consult if symptoms persist.

Conclusion: Several guidelines from the Arthritis foundation are utilized in formulating an evidenced based care plan for MR. Santa Cruz’s osteoarthritis treatment. Guidelines from the U.S. Department of Health and Human Services National Digestive Diseases Information Clearinghouse (NDDIC) information on gastritis are used for the treatment of the patient’s gastritis.
Analgesic medications are the most commonly prescribed medications for the treatment of osteoarthritis pain and are recommended for patients with moderate symptoms (Arthritis Foundation, 2011). Tramodol is selected because it does not have Tylenol as a component and the patient can continue to use Tylenol for the knee pain. For the patient’s inflammation a NSAID is also prescribed and is recommended by the Arthritis foundation. These medications work by blocking the prostaglandins and reduce both pain, inflammation and muscle cramps (Arthritis Foundation, 2011). Physical and occupational therapy is useful to assist with range of motion, flexibility, and mobility issues. The physical therapist prescribes an exercise program, and assists with pain control techniques (Arthritis Foundation, 2011).
Glucosamine is an amino sugar that has a role in the formation of cartilage and repair of cartilage. Chondroitin sulfate is part of a protein that gives the cartilage elasticity. Studies show that people who take these supplements report similar relief of pain to those achieved with non-steroidal anti-inflammatories. This supplement has been used on horses, dogs and in Europe on humans for years to treat arthritis. If the patient does not have relief in six to eight weeks the supplement will probably not work (Arthritis Foundation, 2011).
The topical analgesic capsaicin uses the natural ingredient in cayenne peppers to relieve pain by causing the release of “substance P”, a neurotransmitter that sends pain signals to the brain. Once the substance P is used up, the pain signal along the neurons is not transmitted. It is recommended by the Arthritis foundation as a treatment option for osteoarthritis (Lifescript, 2011), (Arthritis Foundation, 2011).
If no improvement in Osteoarthritis noted, consider intra-articular corticosteroid injections. Steroids are recommended as an alternative treatment for people who do not respond to acetaminophen. The number of injections into a single joint is limited to three or four injections (Arthritis Foundation, 2011).
The patient also is complaining of burning epi-gastric pain; is showing a reduction in his H & H, and is complaining of black tarry stools. The most common cause of erosive gastritis is prolonged use of anti-inflammatory medication use. Symptoms include burning epi-gastric pain and black tarry stools. If left untreated it can cause ulcer formation, and possibly lead to gastric cancer (U. S. Department of Health and Human Services, 2011).
The patient is started Vimovo 375/20 mg PO 1 tablet BID. This medication is a combination of an NSAID to inhibit prostaglandin secretion and reduce pain and inflammation. It also has a PPI that works to protect and heal the mucosal lining. The patient requires long term therapy because of the chronic NSAID use (U. S. Department of Health and Human Services, 2011), (Webmd, 2011).
Gastritis is diagnosed with endoscopy or an UGI series. An UGI is ordered and the patient is referred to gastroenterology for an endoscopy if medication management is ineffective (U. S. Department of Health and Human Services, 2011). The patient is anemic and this could signify chronic bleeding of the mucosal lining, after a week of treatment the patient will have a repeat CBC. JS is sent home with stool cards and instructed in obtaining two additional stool samples.
Because of the potential for acute GI bleed, the patient is instructed to go to the ER for weakness, dizziness, or vomiting of blood. He is instructed to return in 1 week, after his repeat CBC. His anemia is evaluated at that time. If continuing to drop a GI consult and hospitalization for rehydration may be needed. Iron therapy is withheld at this time because of GI irritation, and the hemoglobin should correct itself.

References
Aim for Health Weight. (2011). Retrieved on November 17, 2011 from http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm method=diseases&MonographId=82&ActiveSectionId=42
Arthritis Foundation. (2011). Osteoarthritis. Retrieved on November 28, 2011 from www.arthritis.org/disease-center.php?disease_id=32
Lifescript. (2011). Pure capsaicin. Retrieved on November 28, 2011 from www.lifescript.com/Health/Alternative-Therapies/Herbs/Capsaicin...
National Center for Complementary and Alternative Medicine: Acupuncture. (2011). Retrieved from http://nccam.nih.gov/research/results/acu-osteo.htm
National Center for Complementary and Alternative Medicine: Osteoarthritis. (2011). Retrieved from http://nccam.nih.gov/research/results/gait/qa.htm
Osteoarthritis. (2011). Retrieved on November 17, 2011 https://online.epocrates.com/noFrame/showPage.do ?method=diseases&MonographId=192
U.S. Department of Health and Human Services. (2011). National digestive diseases Information clearinghouse (NDDIC). Gastritis. Retrieved on November 30, 2011 from digestive.niddk.nih.gov/diseases/pubs/gastritis/#4
U.S. Preventitive services task force guide by clinical preventive services, (2007).
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esomeprazole+Or…