Based on the symptoms he is presenting with I would think he is more than likely suffering from osteoarthritis but in order to give him a definite diagnosis and proper treatment further information and testing needs to be obtained. Pain can be caused from an inflammatory, mechanical, or degenerative process so the first step would be to get a better understanding of the chronology and aggravating factors of the pain. I would ask about the onset of the pain, its progression, the timing of the stiffness or pain, aggravating or relieving factors, and presence or absence of fatigue. I would obtain a through past medical and surgical history along with his family history, medication history, and allergic history (Gotlieb, 2005). I would also order a uric acid level to rule out gout and obtain an X-ray to see if there is any narrowing of the spaces between the bones revealing cartilage loss confirming a diagnosis of osteoarthritis. …show more content…
I would encourage MP to try more conservative methods of pain control before having cortisone injections since the injection can actually cause more joint damage over time ("Osteoarthritis - mayo clinic," 2014). I would recommend using Acetaminophen 650mg orally every 4 hours not to exceed 4000 mg in 24 hours along with Naproxen 500 mg bid since Advil no longer seems to be working for him (Woo & Wynne, 2012). I would refer him to a physical and occupational therapist in order to develop an exercise program that will assist weight loss and muscle strengthen without placing improper stress on the joints. I would follow up with him in 1 week to see how he is progressing then again in 1