Patient’s Chief Complaints and History of Present Illness 

PATIENT CASE

Patient’s Chief Complaints and History of Present Illness 

M.L. is a 50-year-old white female who has been working in the front office of a medical clinic for the past five years. She has made an appointment to see her primary care provider because she has been feeling very tired for the past month and has also been suffering from stiffness, pain, and swelling in multiple joints. “I ache all over,” she told her PCP, “and I have pain in different places all the time. One day it is in my right shoulder, the next day in my right wrist, and the following day in my left wrist. I’m stiff everywhere when I get up in the morning or if I sit for any length of time. And I feel so tired, like I have a case of the flu that won’t go away.” The patient is allergic to IV iron dextran from which she has developed shortness of breath. She rarely uses alcohol and does not smoke. She is taking an over-the-counter calcium supplement, levothyroxine sodium, and venlafaxine. There is no family history of rheumatoid arthritis.

 

Physical Examination and Laboratory Tests

The patient is pleasant and alert, but appears very tired. She is in moderate acute distress from joint pain.

Vital Signs BP  125/80 left arm, sitting; P  80; RR  15; T  100.0°F; Ht  54; Wt  140 lbs

HEENT

• Head atraumatic

• PERRLA

• Normal funduscopic examination

• EOMI

• TMs intact

Skin 

• Intact, warm, pink, and dry • No rashes • Normal turgor

Neck 

• Supple with no jugular vein distention or thyromegaly

• No bruits

• Mild lymphadenopathy bilaterally

Lungs 

• Clear to auscultation and percussion

Heart

• RRR • Normal S1, S2; no S3 or S4 • No murmurs, rubs, or gallops

 Abdomen

• Soft, non-tender, and non-distended • Positive bowel sounds throughout • No superficial veins or organomegaly

Breasts No lumps, dimpling, discharge, or discoloration

Genitourinary

• Last menstrual period 16 months ago • Normal pelvic exam and Pap smear

Neurologic

• Alert and oriented  3 • Cranial nerves II-XII intact • Muscle strength: 5/5 upper extremities, 4/5 lower extremities • DTRs 2 in biceps, triceps, and patella

Rectal Heme-negative stool

Musculoskeletal, Extremities • No clubbing or ankle edema • Hands: Swelling of the 3rd, 4th, and 5th PIP joints bilaterally; pain in the 4th and 5th MCP joints bilaterally; poor grip strength bilaterally • Wrists: Good range of motion, fixed nodule at pressure point on left side • Elbows: Good range of motion, fixed nodule at pressure point on right side • Shoulders: Pain and decreased range of motion bilaterally • Hips: Good range of motion • Knees: Pain, significant edema, and decreased range of motion bilaterally • Feet: No edema, full plantar flexion and dorsiflexion and full pedal pulse bilaterally

 

Laboratory Blood Test Result

s Na 140 meq/L ANA Negative Hct 43% Uric acid 2.9 mg/dL K 3.7 meq/L ESR 38 mm/hr WBC 15,100/mm3 Cholesterol 189 mg/dL Cl 104 meq/L Cr 1.0 mg/dL Plt 270,000/mm3 Albumin 4.0 g/dL HCO3  23 meq/L Glucose, fasting 94 mg/dL RBC 4.7 million/mm3 TSH 1.7 µU/mL BUN 18 mg/dL Hb 14.9 g/dL Ca2 8.8 mg/dL RF Positive

Urinalysis Normal with no RBC, WBC, or protein Bruyere

Chest X-Ray No fluid, masses, infection, or cardiomegaly

Hand X-Ray Soft tissue swelling and bone demineralization; no erosions

Synovial Fluid Analysis (Left Knee) • 7.4 mL volume • Cloudy and yellow in appearance • 14,000 WBC/mm3, primarily neutrophils • Glucose: 60 mg/dL

 

Questions: 

 

1. Which of the vital signs above is consistent with a diagnosis of rheumatoid arthritis and why?

 

 

2. List two conditions for which the drug venlafaxine is often prescribed.

 

 

3. Identify two abnormal findings from the physical exam above that are consistent with rheumatoid arthritis.

 

 

4. What is the association between the “fixed nodule(s) at pressure point(s)” on the left wrist/right elbow and a diagnosis of rheumatoid arthritis?

 

 

5. Why is it reasonable that this patient has no stiffness, pain, or swelling in the DIP joints of the fingers?

6. Identify three abnormal laboratory tests that are consistent with a diagnosis of rheumatoid arthritis.

 

 

7. Why is it entirely appropriate that the PCP has ordered a TSH test for this patient?

 

 

8. Provide a reasonable explanation for the serum uric acid test result?

 

 

9. What is probably the first class of drugs that the PCP will prescribe for this patient?

 

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