Question

HPI: SM is a 22 yo female presents to the exam room complaining of (c/o) aching joints including her knees, hips, elbows and wrist progressively worsening over the previous 4 weeks. She states she so tired she has been unable to work for the past week. Then this morning, she woke up with a non-itching rash across her nose and cheeks. PMH: Depression Medication: sertraline FH: Mother alive @ age 47 with hypothyroidism Father deceased @ age 50 due to motor vehicle accident (MVA) 2 Brothers ages 26 and 30 both healthy SH: No Smoking, No Drugs. She is currently attending the local community college majoring in Education. She does not exercise much as she is always studying as exams are coming up soon. ROS: ROS: General: + weight loss, + fatigue, +intermittent fever HEENT: NEG for headache, congestion, nasal drainage, vision problems, throat pain Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness Resp: + Dyspnea, Neg for cough, wheezing, PND GI: + Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia MS: + Joint pain, +Joint Swelling, Neg for falls HEME: + bruising on lower legs, NEG for bleeding, night sweats ENDO: Neg for thirst, heat or cold intolerance NEURO: + dizziness, Neg for confusion, numbness, aphasia PSYCH: + memory loss, Neg for nervousness, suicidal ideation VS: Ht: 5’2 Weight 145 BP: 145/80 HR: 85 Resp: 16 Temp: 98.6 O2 Sat: 94% Physical Exam: Alert, Oriented 22 y o female who appears her stated age. Appropriated dressed and well groomed, NAD HEENT: Normocephalic, Long brown hair w/o alopecia. PERRL, Nasal turbinates w/o discharge TM clear, Pharynx w/o enlargement or erythema. Macular erythema rash across cheeks and nasal bridge. Chest: Reg S1S2, No murmurs, rubs or gallops, No pain Lungs: Clear with equal bilateral breath sounds Abdomen: Soft, non-tender, Bowel Sounds equal x 4 quads, Neg. HJR, Hepatomegaly, or Splenomegaly Extremities: Bilateral Elbow swelling and tenderness with FROM, R Knee Swelling > L Knee Swelling with erythema and tenderness. R Knee with limited extension. Psych: quiet, depressed mood, appropriate language, insight Initial Labs: WBC 4000 /ul Sodium: 145 mEq/L RBC 4.1 Potassium: 4.3 mEq/L HGB: 13.3 g/dl Chloride: 125 mEq/L HCT: 38% CO 2: 25 mmol/L Platelet: 120,000/mm3 BUN: 9 mg/dl Cr: 1.0 mg/dl Discuss the problematic findings within this case. List your differential diagnoses. What additional tests would you order to finalize or Rule Out your diagnosis. What are the 4 criteria presented here needed to finalize the diagnosis?

Answer 1

Problematic Findings and Differential Diagnosis:

The history and physical examination of this patient denote that the patient is having joint ache around her knees, elbows, wrist, and hip for the past four weeks only. This shows the patient may have rheumatoid arthritis. Swelling and tenderness present on both the elbows and legs determine the patient may suffer from synovial inflammation. Connective tissue disorder also has similar symptoms of swelling, tenderness, joint ache. The history of fatigue, dyspnea, weight loss, intermittent fever, macular rash suggests systemic Lupus Erythematous. Nausea, dizziness, dyspnea, indicates chlamydia infection or Lyme disease. Joint pain, bruising in the legs may also suggest the patient may suffer from gout.

Additional tests:

• CBC, ESR, CRP, which gives an additional clue.
• Rheumatoid factor, CCP antibody to suspect rheumatoid arthritis.
• Antinuclear antibody to rule out SLE.
• Urinalysis, serum uric acid to rule out gout.

List of four criteria to finalize the diagnosis

• Site of location and joint involvement

- Level of involvement of the shoulder, hip, elbow, knees, wrist.

-Level of involvement of metacarpophalangeal and interphalangeal joint.

• Serological abnormality

- presence of positive and upper limit of the blood test level.

• Acute phase response

-Elevation of ESR, CRP.

• Duration of symptoms.