PART 1:
Jonathon is a 56 year-old retired automobile mechanic who has not been to
the doctor in approximately 6-7 years. He presents to your office
complaining that three weeks ago he was awoken with severe pain and
inflammation in his knee, which has been consistent since that initial night.
...
part 1 jonathon is a 56 year old retired automobile mechanic who has not been to the doctor in approximately 6 7 years he presents to your office complaining that three weeks ago he was awoken with
Written for
Chamberlain College Of Nursing
NR 508 Advanced Pharmacology
All documents for this subject (83)
Seller
Follow
Themanehoppe
Reviews received
Content preview
NR 508 Week 6 TD, Quiz and Summary
PART 1:
Jonathon is a 56 year-old retired automobile mechanic who has not been to
the doctor in approximately 6-7 years. He presents to your office
complaining that three weeks ago he was awoken with severe pain and
inflammation in his knee, which has been consistent since that initial night.
Upon physical examination of his knee, it appears swollen and erythematous
with periarticular involvement. Upon physical examination and laboratory
results you notice the following:
Physical examination:
GEN: well nourished, obese male (310 pounds)
VS: BP 191/112 HR 75 RR 15 T 98.6, HT 5’8”
EXT: Knee joint inflammation
Laboratory (fasting):
Na 139 mEq/L
K 3.8 mEq/L
Ca 9.1 mg/dL (9-10) Low Normal
CL 102 mmol/L (98-106)
HCO3 22 mEq/L
BUN 10 mg/dL
SCr 0.9 mg/dL
Serum Uric Acid 6.5 mg/dL (4-8.5) (>6.5 hyperuricemia)
Alb 4.1 g/dL (3.5-5)
Cholesterol 300 mg/dL (<200) H
UA: pH 6.8 (4.6-8) , uric acid 250 mg/24h (250-750)
What problems can be identified in this patient? Please provide a list of
differential diagnoses, as well as indication of your primary diagnosis.
What is your pharmacological plan for your primary diagnosis including the
medication, dose, and mechanism of action?
,Pseudogout. Pseudogout, also referred to as acute calcium pyrophosphate
crystal arthritis, is an inflammatory disease process that belongs to a class of
diseases called calcium pyrophosphate deposition diseases (CPPDs) (Rho,
Zhu, Zhang, Reginato, & Choi, 2012). The two prevalent crystal-induced
arthropathies are gout and pseudogout (Rothschild, 2017). Sometimes,
pseudogout and its symptoms can be indistinguishable from gout
(Rothschild, 2017). Symptoms of both diseases include crippling pain in one
or more joints as well as erythema, warmness, tenderness, and swelling
(Rothschild, 2017). These symptoms generally effect the larger joints, such
as the knees and wrists (Papadakis & McPhee, 2017). When the affected
joint is examined via diagnostic imaging, chondrocalcinosis is almost always
present (Papadakis & McPhee, 2017). If the patient presents with the
symptoms above plus a fever, an infection of the joint should be investigated
(Rothschild, 2017).
There are some studies that can be useful in diagnosing, which include urine
and serum uric acid levels (even though these labs are not considered
diagnostic) and blood work such as a CBC to evaluate WBCs, a cholesterol
panel, a renal panel, liver enzymes, and glucose levels (Rothschild, 2017).
An ultrasound can be used to visualize the joint and examine for crystals,
tophaceous materials, and erosions that have overhanging edges (Rothschild,
2017). However, the best way to distinguish between gout and pseudogout is
to aspirate the synovial joint fluid; calcium pyrophosphate crystals indicate
pseudogout while monosodium urate monohydrate crystals indicate gout
(Rothschild, 2017).
Gout and pseudogout are treated similarly; both aim at reducing pain and
preventing flares via medications and/or decreasing urate levels (Rothschild,
2017). Before making a decision on the treatment plan, the provider needs a
baseline of renal functioning, to make sure the diagnosis is not septic
arthritis, and to know if the patient has a history of GI complications,
especially bleeding (PDR, 2017). Once crystal deposits are confirmed, relief
of pain and inflammation can be treated with NSAIDs, adrenocorticotropic
hormone (ACTH), colchicine, or a combination of meds including
intraarticular glucocorticoid (Rothschild, 2017).
For Jonathon, he is experiencing symptoms that could be either gout or
pseudogout. Based on the information given, I chose pseudogout because,
even though uric acid levels are not considered a diagnostic tool, his serum
and urine levels are within normal limits. Assuming he is afebrile and the
, pain and inflammation is not from an infection, I would aspirate some
synovial fluid from his effected knee and analyze it for specific crystal
formation. I would also order an ultrasound of his knee to evaluate for
crystal or tophi development. Assuming the results are positive, I would
make sure to have certain labs done, such as a CBC with diff, CMP, renal
panel, and liver panel for baseline results. I would also inject Triamcinolone
40mg with 1 percent lidocaine into the intraarticuar knee space. I would also
have him take Ibuprofen 800mg Q6H prn for pain until pain is tolerable.
Colchicine 0.6mg PO QD or BID, can be effective in preventing recurrence
in both diseases, therefore could be another treatment option if the above
does not work (Rothschild, 2017).
Triamcinolone is a corticosteroid that provides vasoconstrictive, anti-
inflammatory, and antipruritic properties (PDR, 2017). Corticosteroids
induce lipocortins, which antagonize phospholipase A2, which in turn leads
to the breakdown of leukocyte lysosomal membranes to discharge
arachidonic acid (PDR, 2017). The release of arachidonic acid inhibits the
release of endogenous inflammatory mediators (PDR, 2017).
Ibuprofen inhibits both COX-1 and COX-2 (enzymes) by blocking
arachidonate binding, which results in anti-inflammatory, analgesic, and
antipyretic effects (PDR, 2017). These enzymes accelerate the conversion of
arachidonic acid to prostaglandin G2 (PGG2), which is the first part of the
process in synthesizing prostaglandins and thromboxane responsible for the
rapid physiological responses (PDR, 2017).
Jonathon is also hypertensive and has high cholesterol. I would double check
to confirm his blood pressure is really 191/112, if so I would start him on
lisinopril 40mg daily. I would have him keep a log of his BP and return in 1
week for further evaluation. For his hyperlipidemia, I would start him on
atorvastatin 40 mg daily at bedtime. Jonathon would be instructed to be alert
for symptoms of myalgia or myopathy/rhabdomyolysis. If symptoms occur,
the patient must stop the medicine and call the office immediately so the
patient can be evaluated I would also encourage him to adhere to a diet and
exercise program, which can assist in lowering his BP and his cholesterol.
Monoarthritis. Monoarthritis is pain or swelling that is present in one joint
(Becker, Daily, & Pohlgeers, 2016). This kind of issue can be self limiting to
one or two joints or it can become a systemic problem, such as a septic joint
(Becker, Daily, & Pohlgeers, 2016). Arthritis is the usual culprit when the
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Themanehoppe. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.99. You're not tied to anything after your purchase.
