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Department of Medicine Grand Rounds Clinical Vignette

Department of Medicine Grand Rounds Clinical Vignette. April 15, 2009 Michael Owen, PGY 2. Chief Complaint. A 55 year old female presented to clinic for routine follow-up. HPI.

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Department of Medicine Grand Rounds Clinical Vignette

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  1. Department of Medicine Grand RoundsClinical Vignette April 15, 2009 Michael Owen, PGY 2

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

  3. 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.

  4. 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

  5. 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

  6. 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

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

  8. Imaging • Xray of hands: no evidence of erosion or cartilage loss

  9. Working Diagnosis • Rheumatoid Arthritis • Hypertriglyceridemia

  10. 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

  11. 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

  12. Final Diagnosis • Rheumatoid Arthritis • Hypertriglyceridemia

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