Transcript Clinical Case

Department of Medicine
Grand Rounds
Clinical Vignette
April 15, 2009
Michael Owen, PGY 2
Chief Complaint
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A 55 year old female presented to
clinic for routine follow-up.
HPI
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The patient reported morning stiffness and
pain in her bilateral MCP, PIP, wrist, knee,
and ankle joints for the past 2 months.
The symptoms improved with
Acetaminophen and Ibuprofen, which she
was taking daily.
Occasionally, she required tramadol as well
to control the pain.
Additional History
Past Medical History:
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Rheumatoid arthritis (diagnosed at age 19)
Hypertension
Mixed hyperlipidemia
Mild intermittent asthma
Past Surgical History:
– Cholecystectomy
Family History:
– Aunt with rheumatoid arthritis
– Father had myocardial infarction at age 60
Social History:
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Married with three adult children
Works as elementary school teacher
Rare alcohol use
Smoked ½ pack per day for 20 years, quit 15 years ago
Additional History
Allergies: No known drug allergies
Medications:
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Ibuprofen 600 mg 3 x per day
Acetaminophen 650 mg q6 hrs PRN pain
Methotrexate 7.5 mg weekly
Tramadol 50 mg q6 hrs PRN pain
Albuterol inhaler PRN wheezing
Hydrochlorothiazide 25 mg daily
Simvastatin 40 mg daily
Physical exam
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General: overweight female in no acute
distress
Vitals: T: 98.8 BP: 132/85 HR: 72 RR: 16
BMI: 29
MCP and PIP: warmth and swelling with
tenderness on palpation, no deformity
Wrist, knee, ankle: mild tenderness
The remainder of the physical exam was
normal
Labs
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Rheumatoid factor: positive
anti-CCP: positive
Total cholesterol: 190
LDL: 88
HDL: 43
Triglyceride: 289
Imaging
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Xray of hands: no evidence of erosion
or cartilage loss
Working Diagnosis
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Rheumatoid Arthritis
Hypertriglyceridemia
Case Follow Up
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The patient was counseled on weight
loss
It was recommended that she start
taking omega 3 fatty acid supplements
(fish oil) for high triglycerides
Case Follow up
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Three months later, the patient
reported less joint pain and less use
of tramadol for breakthrough pain
Repeat lipid panel showed
Total cholesterol: 180
LDL: 93
HDL: 55
Triglyceride: 157
Final Diagnosis
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Rheumatoid Arthritis
Hypertriglyceridemia