Question

DISCHARGE SUMMARY

Admission Diagnosis: Multiple compression fractures of T12, L1, L2, and L4

Discharge Diagnosis: Same as above, non-acute fractures

History of Present Illness: This is a 70-year-old African-American female with a long history of multiple fractures dating back to 1992. She has a history of significant osteoporosis diagnosed in 1998. The patient also has a history of osteoarthritis and had a right total hip replacement in 2000. Two days prior to admission, the patient missed the final step coming down the stairs in her home. She caught hold of the railing but twisted as she did so and developed some back pain. This became progressively worse over the next 2 days to the point where she was having difficulty ambulating and she went to the Emergency Room.

On evaluation in the ER, it was noted that she had compression fractures of the T12, L1, L2, L3, and L4 vertebrae. However, these could not be ruled out as new or old fractures due to lack of previous X-rays in this area. The patient was admitted for further evaluation.

Past Medical History: The patient is retired and lives in an independent living apartment in the Pine Valley retirement community. She does not smoke and has no alcohol intake. She has osteoporosis and osteoarthritis. Also of note is that approximately 10 days prior to admission, the patient had sustained a distal radius fracture of her left forearm for which she was treated with a splint by an orthopedist.

Physical Examination: This is a well-developed, well-nourished elderly female in no acute distress. She had moderate discomfort on movement. Her HEENT exam was essentially normal. Her lungs were clear. Heart had a regular rate and rhythm. Abdomen was soft and nontender. Her rectal area showed good tone. Her back showed moderate tenderness to palpation in the upper lumbar and lower thoracic area. Neurologically, she was completely normal with cranial nerves being intact. Motor was 5/5 in all extremities except for the left extremity, which was not examined secondary to the arm being in a splint. She had deep tendon reflexes 2+ and equal. Her sensory exam was normal.

Hospital Course: The patient was admitted and on the day following admission, she had a bone scan that revealed moderate degenerative joint disease of the T&L (thoracic and lumbar) spine with no evidence of acute compression fractures. The patient was placed on bed rest and was started with physical therapy and ambulation with which she has steadily progressed with decreasing pain and tenderness. The patient is now ambulating using a walker with a platform for her wrist splint.

Social Services and Physical Therapy were consulted. She is ambulating well with her walker and it is felt she will do well staying with members of her family over the next 10 to 14 days, after which time she will be able to go back to living in her apartment.

The patient will follow up with the Orthopedic Clinic in 10 to 14 days. She will follow up with her private physician for the wrist fracture upon discharge.

Discharge Medications: Tylenol #3, one or two p.o. q 4-6 h. p.r.n.; Fosamax 5 mg daily, and she will continue with her Calcium t.i.d.

OUTPATIENT OFFICE ENCOUNTER

Carol Champion is a 46-year-old retired professional ice skater who was seen initially by Physical Therapy on 12/30/10. She indicates that she fell on her left shoulder and arm while ice skating on 12/29/09. She was first seen by Beth Ranowski and given Codman's exercises. The patient continued to have shoulder pain and saw Dr. Owens on 1/04/10 and was referred for physical therapy due to her complaints of limited range of motion in the left shoulder secondary to pain. Her assessment was rotator cuff of the left shoulder with limitations in active range of motion.

DISCUSSION QUESTIONS

1. Review the Discharge Summary, provide the following in your post.
   1. What does it mean in the spinal X-ray when it says, "These could not be ruled out as new or old fractures?"
   2. What other terms in this case study refer to structures and conditions of the musculoskeletal system?
2. Review the outpatient encounter of Carol Champion,provide the following in your post.
   1. What advice would you offer Carol Champion regarding what she should do if the physical therapy does not resolve the shoulder pain?
3. General questions:
   1. What are the major structures of the bone and their respective subcategories?
   2. Define each term into its common word parts. Write these word parts in sequence; use a slash when necessary to indicate a combining vowel.
      1. Bursectomy
      2. Osteochondroma
      3. Osteomalacia
      4. Periostitis
      5. Tendonitis
      6. Spondylosis

Answer 1

* They cannot rule our they are new or old fractures because patient was already suffering from osteoporosis and osteoarthritis,so there are chances that she may have got the injury before admission in the hospital also.

*Terms used regarding musculoskeletal system.

• Multiple fractures
• Osteoporosis
• Osteoarthritis
• Compression fractures
• T 12,L1,L2,L3,L4 VERTEBRAE
• distal radius fracture
• Left fore arm
• Deep tendon reflexes
• Degenerative joint disease of thoracic and lumbar spine
• Wrist

*If the pain doesn't subside for the patient even after the physical therapy she should go for a surgery.

If it's mild pain, anti inflammatory drugs,cold compression,heat therapy,rest and excercise would work,but if it is severe,she need to go for surgery.

*Major structures of bone:

There are three types of bone tissue

• Compact tissue- harder and outer part of the bone
• Cancellous tissue:sponge like inside the bone
• Sub chondral tissue- smooth tissue at the end of the bones which is covered by another tissue called cartilage.
• Periosteum-tough thin outer layer covering bone .

Beneath the harder outer shell of periosteum are tunnels and canals through which blood and lymphatic vessels run to carry nourishment for the bone.

*BURSECTOMY:

Surgical removal of bursa , usually due to treatment-refractory inflammation.

OSTEOCHONDROMA:

An abnormal, solitary,benign growth of bone and cartilage , typically at the end of long bone.

OSTEOMALACIA:

Softening of bone , particularly in sense of bone weakened by demineralisation and most notably by depletion of calcium.

PERIOSTITIS:

Inflammation of periosteum.

TENDONITIS:

Also known as tendintis is inflammation of tendon.

SPONDYLOSIS:

Refers to degenerative process affecting vertebral disc and facet joints that gradually develops with age.

GOOD LUCK!!!