Case Study of a Patient With Chronic Bilateral Hip Pain

The patient is a 73-year-old male, Mr. R.B, who has been admitted at Sylvale with acute on chronic bilateral hip pain as the chief complaint. Having been transferred from rehabilitation, the patient is currently awaiting electric hip replacement at the health care facility. Mr. R.B has been suffering from deep vein thrombosis (DVT), a blood clot condition that develops within the deep vein of his leg and has been using apixaban. For this reason, the patient's prior admission plans were canceled. He also had had a fall and was recovering at Sylvale. A historical assessment of Mr. R.B shows that the patient had Chondrocalcinosis on the right knee. An X-ray done on the pelvis showed severe osteoarthritis (OA) with posture avascular necrosis of hips, creating the need for hip replacement. Previously, Mr. R.B had been diagnosed with gastritis on the endoscopy in 2018 and chronic back pain and had undergone through splenectomy 30 years ago following an accident. He had also suffered from Hypertension (HTN), Gout, and diverticulosis. Besides, the patient had been treated with enlarged prostate through Transurethral resection of the prostate (TURP).

Owing to his complicated medical history, Mr. R.B has undertaken a wide range of medications, including Allopurinol, betamethasone topical, cephalexin, perindopril- indapamide, oxycodone, apixaban, and paracetamol. His home had been modified to suit his special medical needs, particularly on the toilet and bathroom, as well as front doors. The patient's wife is also ailing from heart problems, although he is unsure of the diagnosis on the medication. He has been married and living with his wife for approximately 54 years and has two grandchildren and two great-grandchildren. Mr. R.B has his own home, and he enjoys outdoor activities. In his spare time, he loves gardening and playing soccer with the local clubs over the weekends. An assessment of the vital signs showed that the patient had blood pressure (Bp) levels of 105/61, oxygen saturation (sp02) of 95010, and a weight of 75. His respiration was 19, pulse rate 85, and body temperature 36.5. The cardiac evaluation showed Hiller venous congestion with the minor lower zone. In contrast, a computed tomography (CT) abdomen scan conducted on 5th April 2019, showed no evidence pointing to the presence of obstructive uropathy or metastatic bone disease. The neurological assessment indicated that the patient is nonetheless alert and oriented.

Pathophysiology

The patient presents a myriad of signs and symptoms during the assessment. Mr. R.B was admitted for acute on chronic bilateral hip pain having been transferred from rehabilitation for electric hip replacement. Bongartz et al. (2015) observe that hip pain is a common condition among the elderly and may cause functional disability. The patient is 73 years old, and this explains the chronic pain. However, the situation was accelerated by the fall for which he was recovering and other health complications. The patient had been diagnosed with osteoarthritis (OA) and gout, conditions that frequently affect the hip areas. According to Doherty et al., (2017), OA is a chronic form of hip arthritis that is characterized by the drastic breakdown of the cartilage that functions to cushion the ends of the bones at their meeting points to form joints.

The absence of these cartilages causes the bones to rub against each other, causing acute pain, stiffness, and even loss of movements. When an X-ray was done on Mr. R.B, it showed that he was having severe osteoarthritis (OA) posture avascular necrosis of hips. Besides, gout is a condition that occurs owing to excess deposits of biological waste products that circulate the bloodstream, uric acid in tissues of the body, and joints (Bang et al., 2016). While Sabchyshyn et al. (2018) observe that gout is less commonly associated with acute hip pain, excess deposits of this uric acid on the hip joints are likely to cause pain in the long run. Overall, given the conditions around the patient's chronic bilateral hip pain, there was a need for him to undergo an electric hip replacement.

Pointedly, Mr. R.B has been suffering from deep vein thrombosis (DVT), which is a blood clot condition that develops within the deep vein of his leg, and this also causes pain, especially on the affected leg. He was also diagnosed with Chondrocalcinosis (CCAL) on the right knee. The condition is a genetic type that is characterized by the deposition of calcium pyrophosphate dehydrates crystals (CPDD) around joint cartilage (Sivera, Andres, & Pascual, 2011). The disease potentially damages the affected joints after some time (Magarelli et al., 2012; Meng et al., 2011). However, Patel et al. (2014) observe that the non-genetic form of CPDD is common among patients who are over 60 years of age and are often associated with arthritis.

The symptoms of this condition include acute and recurring attacks of pain on the affected regions, swelling, and redress of the joints. According to Suva and Patel (2014), calcium pyrophosphate may also accumulate around the vertebrae (the bones of the spine), causing severe back or neck pain and may lead to loss of mobility. Most patients suffering from this condition are likely to develop chronic arthritis resembling osteoarthritis as well. In 2018, an endoscopy on the patient revealed that he was suffering from gastritis. He had also gone for splenectomy after an accident. According to an article by Nel (2013), gastritis is a condition that is characterized by inflammation or erosion of the inner lining of the stomach causing vomiting, nausea, indigestion, and abdominal bloating and pain. From the assessment, Mr. R.B was reported to experience nausea vomiting that was associated with constipation. Subsequently, his potassium was replaced, and he was also given phosphate and magnesium as supplements.

Pharmacological Treatments

The patient would undertake a series of pharmacological treatments owing to his myriad health problems. Given that the pressing issue for which Mr. R.B is admitted is the acute, chronic bilateral hip pain as the chief complaint, the initial treatment procedures would aim to relieve him from the condition. The patient has been prescribed a total hip replacement or what Langton et al. (2011) regards as hip arthroplasty. The medical procedure is a technique that was developed as a response to the need for an enhanced hip joint movement that had suffered damages by injury or arthritis. According to Meek et al. (2011), unlike other alternative medication and treatment plans, joint replacement surgery provides the best treatment option for long-term improvement for the hip joint.

In most cases, a total hip replacement relief the patient from joint pain and may also fast track a return to a pain-free movement. Knight et al. (2011) observe that the most significant benefit and reason for the total hip replacement surgery procedure are to eliminate the chronic pain on the patients. It also enhances movement, strength, and proper coordination between the leg and torso (Watson et al., 2016). While the surgery may not provide Mr. R.B an active lifestyle given his age, it might improve his overall wellbeing as well as eliminate the acute bilateral hip pain.

The patient was also prescribed various medications for treating different aspects of his condition. The physicians administered allopurinol, which is a medication used to treat gout as well as to prevent increased uric acid levels around the joint regions. Thanassoulis et al. (2010) observe that this medicine works by reducing the amount of uric acid accumulation in the body. The drug is taken orally daily as prescribed by the physicians. Continued use of the drug is likely to cause nausea, stomach upsets, drowsiness, or even diarrhea.

Betamethasone topical is used to prevent the release of substances in the body that leads to inflammation. The drug is best used externally, and the patient is encouraged not to take it by mouth and not on open wounds. Since Mr. R.B was diagnosed with deep vein thrombosis (DVT), the use of Betamethasone topical could help reduce the inflammation of the leg (Watson et al., 2016; Kesieme et al., 2011). Besides, Kesieme et al. (2011) observe that the condition is best treated with anti-coagulants, also referred to as blood thinners. The drugs are either injected or taken orally reduces the ability of the blood of the patient from clotting. While the medicine may not break down already clot blood, it helps prevents the clots from expanding as well as reducing the risk of developing more clots. For critical cases, Casey et al. (2012 observe that the doctor may prescribe patients with severe deep vein thrombosis clot busters to help break up the clots quickly and prevent inflammation of the leg.

Furthermore, the patient would be given cephalexin, which is an antibiotic that fights bacteria in the body. To relieve his ongoing pain, the physicians would administer oxycodone and naloxone. According to Kokki et al. (2012), oxycodone belongs to the class of drugs called opioids (narcotic) analgesics, which operate in mind to alter how the body feels and responds to the physical pain. On the other hand, naloxone acts as an opioid blocker that is used to prevent particular forms of abuse of opioid medications. Besides, the patient would also prescribe paracetamol that would function as a pain reliever.

Besides, the administration of magnesium aspartate and monobasic sodium phosphate (MSP) to the patient would boost his levels of phosphate and magnesium. According to Mauskop and Varughese (2012), magnesium aspartate is a medication that is used as a mineral supplement to prevent as well as treat low amounts of magnesium in the patient's blood. It is also used to treat symptoms of excess stomach acid, leading to stomach upset and acid indigestion. On the other hand, monobasic sodium phosphate (MSP) is an inorganic compound of sodium that is used to treat constipation and clean the bowel before surgery, endoscopy or x-ray (Hussein Thabeet, 2012). Some of the common side effects of this medication include bloating, stomach pain, nausea, and vomiting. Besides, potassium chloride would be used to prevent and treat low blood levels of potassium, which could have been caused by prolonged illness with vomiting and diarrhea.

For the DVT, Mr. R.B has been prescribed rivaroxaban, which is often used to block the ongoing activities of clotting substances in the blood. In general practice, the medication is used to prevent and treat a specific type of blood clot, namely deep vein thrombosis for which the patient is being treated (Watson et al., 2016). The patient would also be prescribed perindopril or indapamide to treat his hypertension (high blood pressure). It is worth noting that prolonged use of this medication may have side effects such as back pain, weight gain, nausea, and dizzy spells.

Health Professionals Role

Providing nursing care for Mr. R.B requires a plan that incorporates different functions of health care professionals to regain his mobility. The care plan should include such activities as informing the patient of the extent of his condition, treatment plan that involves surgery, assessment, and monitoring of his anticoagulant therapy, ensuring that Mr. R.B has comfort measures. Others are maintaining sufficient tissue perfusion, ensuring that the patient engages in physical exercise and patient monitoring to avoid any possible complications (Lloyd et al., 2012). Accomplishing these activities requires the duties of trained health professionals to enable Mr. R.B to regain his optimum functionality.

Orthopedics

Orthopedics health professionals are trained in the treatment of musculoskeletal systems. These surgeons deal with patients suffering from illnesses that relate to bones, muscles, joints, tendons, and ligaments (Saleh, El-Othmani & Saleh, 2017). The professionals, therefore, play a critical role in providing clinical care for patients like M.R. R.B. through a preventive care approach to reduce the prevalence of his chronic conditions. Mr. R.B's conditions require the immediate attention of an orthopedic surgeon to minimize the extent of his chronic back pain and severe osteoarthritis (O.A.) through hip replacement. His medical history increases his risks of deep vein thrombosis (DVT), creating the need for orthopedics. In working with the patient, these professionals will focus on reducing the pain Mr. R.B is experiencing in his leg, then improving his joint, muscle, and body movement (Larson et al., 2011). This process will be done through strengthening, stretching, exercise, and physical therapy to enable him to regain his mobility.

Physicians and Pharmacists

Physicians are essential in providing care to the patient in both the in-patient and outpatient care settings. These groups of practitioners are in close contact with the patient; hence, they can build a personal relationship that enhances understanding of the illness. The physicians will provide counseling to the patient to avoid and modify the risk factors that expose him to DVT and design appropriate physical exercise that improves his mobility throughout his recovery process (Popuri & Vedantham, 2011). In essence, the physicians will help the patient manage the patient's chronic conditions over the extended period of recovery by providing regular health maintenance.

On the other hand, pharmacists will help in ensuring that the patient is given the correct prescription and assess the quality of medicine supplied to the patient in accordance with his illness. Moreover, the pharmacist will provide advice to the patient on how to take the prescribed medication and possible side effects of their usage and how to limit these risks (Dunn & Ramos, 2017). Through their roles, these professionals will ensure that Mr. R.B is given the right form of medication that will enhance his quality of life.

Nurses

Nurses provide immediate care plans to patients suffering from deep vein thrombosis during their recovery processes. The specialist nurse-led DVT teams at the Sylvale health care center will work with the patient to provide services in both in and outpatient basis. This care plan incorporates various key roles for nurse practitioners. Nursing roles, as noted by Songwathana, Promlek, and Naka (2011), will include an assessment to determine the extent of the DVT to provide an appropriate diagnosis. Some of the diagnosis that can be carried out by the nurses on Mr. R.B include impaired comfort due to vascular inflammation, ineffective tissue perfusion from venous blood flow interruption and risk of impaired physical mobility that creates discomforts (Collins et al., 2010; Strijkers et al., 2011). Since Mr. R.B is in-patient at the clinic, nurses will provide comfort through graduated compression antiembolism stockings (AES). Nurses will carry out a physical assessment of the presence of any contraindications and help the patient in fitting the correct stockings as prescribed (Meneilly & McCutcheon, 2013). During the process, the nurses will check the patient's skin integrity regularly and communicate to the patient on how well to wear and care for the AES.

Allied Health Professionals

Based on his medical condition, Mr. R.B is exposed to the risks of additional illnesses that require the attention and skills of allied health professionals. Allied health professionals are essential in enabling the patient to cope with his life-limiting illness by providing multidisciplinary support that ranges from nutrition, medication, communication, and mobility (Dunn & Ramos, 2017). The allied health professional plays a vital role in helping the patient regain his functionality and independence, providing emotional support, connect him to additional supportive services having been discharged, and planning future care plans to avoid recurring (Meneilly & McCutcheon, 2013). Physiotherapists and psychologists will provide palliative care for Mr. R.B to maximize the quality of his life as he regains his health. The psychologist will help the patient in understanding the interrelationship between his physical health condition and emotional distress and design a care plan for coping.

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