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Week 14 - Case Study

Overview

Mrs. Johnson is a 73 y.o. female who presents to your office with right shoulder pain. Her and

her husband just moved to the area a few months ago, and you have only seen her once for a

sinus infection. Today she states that she is having increasing right shoulder pain over the past

couple of weeks. She explains that her shoulders have “always bothered” her because she

worked in a factory moving boxes for years. She states that she uses naproxen, “prescription

strength” and that usually does the trick when her arthritis flares up, but she is out and would like

a refill.

On exam, you note that her right shoulder is tender to palpate, and she has limited motion. She

smells of BenGay but otherwise, she seems healthy. The area is edematous and when asked she

does agree that her arm seems swollen. She denies any falls but remembers that she lost her

balance and fell backward into her recliner a few days ago “kind of hard” but she caught herself

when she grabbed for the coffee table. Otherwise, she does not recall any injuries. You decide to

send Mrs. Johnson for an x-ray and she is in the waiting room until you get the results back.

The following radiograph is what is sent to you via teleradiology.

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Questions to answer

Two pages, APA, 3 references.

1. What is in your differential diagnosis (top 3 minimum) as you think through this case?

What would you order, if anything?

2.

What else would you like to ask Mrs. Johnson relating to how she may have been injured?

3.

There are at least two areas of concern on this x-ray—one is a pathological fx of her humerus.

Research pathological fractures; review the physiology of the musculoskeletal system and

compare and contrast this knowledge with this pathophysiological condition.

4.

After focusing on the pathophysiology of the fractured bone, discuss what other disorder you

suspect from a review of the x-ray.

5.

What would be your primary choice for an underlying diagnosis for Mrs. Johnson, and why?

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6.

What past pertinent information related to a pathological fracture and your second suspected

diagnosis would you like to ask Mrs. Johnson?

7.

Are there any additional tests, radiological studies, etc. that you would order for Mrs. Johnson?

Will you refer this patient, and if so, to whom?

Sample answers. Paraphrase them.

The x-ray indicates a pathological fx of her humerus. What is a pathological fracture? A

pathologic fracture is a broken bone that’s caused by a disease. This is due to weakness in

the bone structure (Morrison, 2017).

What can cause a pathological fracture? The pathological conditions that can cause

pathological fractures are osteoporosis, cancer, osteomalacia, and osteomyelitis.

Based on the history provided in the first paragraph, what other musculoskeletal problem

do you suspect? What is the pathophysiology for this? In this picture one will have to rule

out malignancy and once that is ruled out then it is invariably osteoporosis. Osteoporosis

is common in post-menopausal women due to lack of estrogen. It is a skeletal disorder

characterized by compromised bone strength predisposing to an increased risk of

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fractures (Manolagas, 2020). Older bone is regularly resorbed at different locations by

osteoclasts during life and replaced by new bone created by osteoblasts. The process is

called remodeling. Remodeling is planned and is aimed at a particular location requiring

osteocyte repair (Manolagas, 2020). The seminal pathophysiological variations in

osteoporosis are an oversupply of osteoclasts relative to the need for remodeling or an

undersupply of osteoblasts relative to the need for cavity repair (Manolagas, 2020)

What are things that can be done to promote healing of a pathological fracture?

Promoting healing involves immobilization. Bone healing is a natural process which

usually occurs automatically (Morrison, 2017). In order for this process to take place, the

bones most be lined up, this process is known as reducing the fracture. Applying plaster

casts or plastic functional braces helps keep the bone positioned during healing (2020). In

addition, taking pain medications, calcium, vitamin D supplements, and bisphosphonates

promotes healing.

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