Department of Medicine Grand Rounds Clinical Vignette

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Department of Medicine Grand RoundsClinical
Vignette

• April 15, 2009
• Michael Owen, PGY 2

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Chief Complaint

• A 55 year old female presented to clinic for
  routine follow-up.

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HPI

• 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.

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Additional History

• Past Medical History
• 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
• 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

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Additional History

• Allergies No known drug allergies
• Medications
• 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

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Physical exam

• 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

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Labs

• Rheumatoid factor positive
• anti-CCP positive
• Total cholesterol 190
• LDL 88
• HDL 43
• Triglyceride 289

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Imaging

• Xray of hands no evidence of erosion or
  cartilage loss

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Working Diagnosis

• Rheumatoid Arthritis
• Hypertriglyceridemia

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Case Follow Up

• The patient was counseled on weight loss
• It was recommended that she start taking omega 3
  fatty acid supplements (fish oil) for high
  triglycerides

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Case Follow up

• 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

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Final Diagnosis

• Rheumatoid Arthritis
• Hypertriglyceridemia