online solution: QuestionAnswered step-by-stepCreate a decision flow chart di

QuestionAnswered step-by-stepCreate a decision flow chart differential diagnosis comparing each of the following: Osteoarthritis, Gout Arthritis and Rheumatoid Arthritis based on the chief complaint signs and symptoms in the given case study below: P.S. Decision flow chart should arrived to the final diagnosis of osteoarthritis.Kindly include diagnostic exams to further verify the final diagnosis which is osteoarthritis Patient’s Chief Complaints”I’m really having trouble getting around. My joints have been killing me. Knees and lower back are the worst. Other doctors won’t give me what I need to feel better.”History of Present IllnessG.J. is a 71 yrs. old overweight woman who presents to the Family Practice Clinic for the first time complaining of a long history of bilateral knee discomfort that becomes worse when it rains and usually feels better when the weather is warm and dry. “My arthritis hasn’t improved a bit this summer though,” she states. Discomfort in the left knee is greater than in the right knee. She has also suffered from low back pain for many years, but recently it has become worse. She is having difficulty using the stairs in her home.The patient had recently visited a rheumatologist who tried a variety of NSAIDs to help her with pain control. The medications gave her mild relief but also caused significant and intolerable stomach discomfort. Her pain was alleviated with oxycodone. However, when she showed increasing tolerance and began insisting on higher doses of the medication, the physician told her that she may need surgery and that he could not prescribe more oxycodone for her. She is now seeking medical care at the Family Practice Clinic.Her knees started to get significantly more painful after she gained 20 pounds during the past nine months. Her joints are most stiff when she has been sitting or lying for some time and they tend to “loosen up” with activity. The patient has always been worried about osteoporosis because several family members have been diagnosed with the disease. However, no clinical manifestations of osteoporosis have developed.Past Medical HistoryAt age 23, the patient suffered a left knee injury in an MVA that did not require surgery. She also suffered a broken left hip 11 years ago when she fell on an icy sidewalk while visiting her sister in Michigan. Her hip seemed to have healed well as she has no significant symptoms that suggest hip joint involvement.The patient has a 14-year history of OA, a 10-year history of HTN, a 4-year history of hypercholesterolemia, and a 4-year history of DM type 2. She also was hospitalized for an episode of diverticulitis two years ago. Her only surgery was a hysterectomy without oophorectomy 21 years ago. Menopause occurred at age 49, but she has never taken hormones.Family History• Father died from AMI at age 53• Mother died from breast CA at age 80•  Patient has one brother, age 68, with HTN; one sister, age 74, who has severe allergies and has had two mitral valve replacements for rheumatic heart disease; and one sister, age 72, who also has OA• Positive history of osteoporosis in mother and maternal grandmother Social History• Lives with her 72 yrs. old sister in a 3-story townhouse near the beach• Exercises regularly in the pool and, sometimes, in the ocean, but can no longer walk long distances daily as she has done in the past• Has a well-balanced diet with plenty of fresh fruits and vegetables, whole grains, and dairy products, but admits to eating “too many sweets”• Has Medicare but no other health insurance• Does not smoke and drinks 1-2 cocktails or glasses of white wine every evening with her meal• Hobbies include quilting, baking, and teaching piano to childrenReview of Systems• Mild pain in right shoulder with lifting, carrying• Low back pain with occasional “shooting pains” radiating to back of thigh• Deep, aching pain in the pretibial area bilaterally and extending distally to the ankles and toes• Patient denies any swollen, red, or hot joints, but notes “hard lumps” at the margins of the interphalangeal joints• Patient denies numbness or weakness in her legs• Patient denies pain or discomfort in her wrists and elbows• Negative for headaches, neck stiffness, SOB, chest pains, urinary frequency or dysuria, constipation, diarrhea, nausea, loss of appetite, or significant changes in the appearance of her urine or stools• Finger-stick blood glucose levels are usually around 180 mg/dL• Occasional polyuria but no changes in visionMedications• Zolpidem 10 mg po Q HS PRN• Atorvastatin 20 mg po Q HS• Atenolol 25 mg po QD• Lisinopril 40 mg po QD• Metformin 250 mg po QD• Glipizide 2.5 mg po QD• Acetaminophen 1000 mg po TID• High-potency multivitamin supplement with calcium, iron, and zinc po QD• Calcium 600 mg with Vitamin D 125 IU supplement po BID with mealsAllergiesNo known drug allergiesPhysical Examination and Laboratory TestsGeneralAlert, WDWN, overweight Caucasian female who appears slightly anxious but otherwise in NAD Vital Signs Patient Case Vital SignsBP sitting, left arm            155/88 RR 15 and unlabored HT 5 ft-3 inP      72 and regular T 98.8°F WT 164 lbs.  Skin Warm and dry with normal turgorNo petechiae, ecchymoses, or rashHead, Eyes, Ears, Nose and Throat NC/ATPERRLANeck and Lymph Nodes Neck supple(-) evidence of thyromegaly, adenopathy, masses, JVD, or carotid bruitsChest Good chest excursionLungs CTA & PBreast SymmetricNo apparent masses, discharge, discoloration, or dimplingAbdomen Soft and non-tender without guarding(+) BS(-) organomegaly, bruits, and massesGenitalia Normal female genitalia(+) mild vaginal atrophyNormal anal sphincter toneStool heme-negativeMusculoskeletal/Extremities Back with decreased flexion and extensionBack pain radiating to right buttock with straight right leg raising >60°Full ROM at left shoulder, elbows, and anklesMild left hip discomfort with flexion >90° and with internal and external rotation >45°Hips not tender to palpationBilateral knee crepitus and enlargement but more pronounced in left kneeSlight decrease in ROM and both Bouchard and Heberden nodes observed bilaterally during hand examination; no tenderness in finger jointsNo redness, heat, or swelling in jointsFeet without breakdown, ulcers, erythema, or edemaNeurologic Oriented X 3Cranial nerves intactSensory exam normal and symmetric to pinprick and vibrationDTRs 2+ and equal bilaterally except for 1+ Achilles reflexes bilaterallyStrength 5/5 in both upper extremities; 4/5 in lower extremitiesGait slow but without specific deficitsCoordination WNLNo focal deficits(-) Babinski bilaterally    Laboratory Blood Test Results  Patient Case Table 78.2 Laboratory BloodTest ResultsNa 137 meq/L MCV 87 fL Protein, total 7.9 g/dLK 4.4 meq/L MCH 27.7 pg Alb 4.2 g/dLCl 108 meq/L MCHC 31.8 g/dL Cholesterol 248 mg/dLHCO3 23 meq/L WBC 5.2 X 103/mm3 HbA1c 7.5%BUN 7 mg/dL Plt 239 X 103/mm3 Ca 8.7 mg/dLCr 0.6 mg/dL AST 31 IU/L PO4 2.9 mg/dLGlu, fasting 241 mg/dL ALT 19 IU/L Mg 1.9 mg/dLHb 13.5 g/dL Bilirubin, total 0.6 mg/dL ESR 14 mm/hrHct 39.1% Alk phos 97 IU/L TSH 1.9 µU/mL  Urinalysis  Patient Case Table 78.3 UrinalysisAppearance Pale yellow, clear Leukocyte esterase NegativeSpecific gravity 1.017 Nitrites NegativepH 6.3 Bacteria NegativeWBC 0/HPF Protein NegativeRBC 0/HPF Ketones Negative X-Rays Lumbosacral spine• Advanced degenerative changes with disk space narrowing and osteophyte formation at L3-4 and L4-5• No evidence of compression fracture Left hip• Mild-to-moderate degenerative changes with mild osteophytosis of femoral head• Slight narrowing in joint space Right and left knees• Moderate degenerative changes with joint space narrowing, subchondral sclerosis, and bone cysts• No radiographic evidence of osteoporosis or joint effusions Right shoulder• Mild degenerative changes with bone spurs at head of humerus• Slight narrowing in joint spaceHealth ScienceScienceNursingNUR 676Share Question

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