Rheumatology Case Study: Patient 1

Laboratory Studies

• Hemoglobin: 12.8 g/dL
• Leukocyte count: 9800/mm3
• Erythrocyte sedimentation rate: 44 mm/h
• Serum:
  • Glucose: 77 mg/dL
  • Creatinine: 1.1 mg/dL
  • Total bilirubin: 0.7 mg/dL
  • Alkaline phosphatase: 33 U/L
  • AST: 24 U/L
  • ALT: 21 U/L
  • Rheumatoid factor: positive

Patient 1

• 42-year-old woman with 8-month history of intermittent pain and stiffness in hands and feet
• Episodes occur 3 times a month, last for approximately 1 hour, and are sometimes accompanied by fever and myalgia
• Takes ibuprofen for pain relief
• Sister has systemic lupus erythematosus
• Vital signs are within normal limits
• Examination shows mild swelling and tenderness of wrists and proximal interphalangeal joints of both hands

Patient 2

• 46-year-old woman with 4-month history of lethargy and joint pain for 15 years
• Temperature: 37.4°C (99.3°F), pulse: 97/min, blood pressure: 132/86 mm Hg
• Physical examination shows pallor of oral mucosa and nontender subcutaneous nodules on both elbows
• Laboratory studies:
  • Hemoglobin: 8.2 mg/dL
  • Prothrombin time: 12 sec
  • Serum:
    • Albumin: 2.8 g/dL
    • Total bilirubin: 1.0 mg/dL
    • Alkaline phosphatase: 80 U/L
    • AST: 20 U/L
    • ALT: 19 U/L
    • Urea: 18 mg/dL
    • Creatinine: 1.2 mg/dL
  • Urine:
    • Protein: 3+
    • WBCs: 5-10/hpf
    • RBCs: negative
    • Bacteria: negative

Patient 3

• 50-year-old woman with worsening pain and swelling of left knee
• For the past year, she has had pain in her knees and hands bilaterally, but never this severe
• During this period, she has also had difficulty moving around for about an hour in the mornings and has been sweating more than usual, especially at night
• She has been sexually active with a new partner for the past 4 weeks and they use condoms inconsistently
• Temperature: 38.5°C (101.3°F), pulse: 92/min, blood pressure: 110/70 mm Hg
• The left knee is erythematous, swollen, and tender, with restricted movement due to pain
• There is swelling of the metacarpophalangeal joints and proximal interphalangeal joints bilaterally
• Arthrocentesis of the knee with synovial fluid analysis shows a greenish, turbid fluid, a cell count of 68,000 WBC/μL, and Gram-negative diplococci

Patient 4

• 47-year-old man with alcoholic cirrhosis
• Examination shows erythema over the thenar and hypothenar eminences of both hands
• He also has numerous blanching lesions over the trunk and upper extremities that have a central red vessel with thin extensions radiating outwards

Patient 5

• 59-year-old man with progressive abdominal swelling and shortness of breath for 1 week
• He drinks 12 to 13 alcoholic beverages daily
• He appears emaciated
• Examination shows pallor, jaundice, hepatomegaly, gynecomastia, and a protuberant abdomen with a fluid wave and shifting dullness

Patient 6

• 61-year-old man with acute myocardial infarction
• He has sharp, substernal chest pain that worsens with inspiration and improves when leaning forward
• Cardiac examination shows a scratchy sound best heard over the left sternal border

Patient 7

• 61-year-old man who died 10 minutes after arrival at the emergency department
• He was brought to the emergency department by ambulance due to severe retrosternal chest pain and shortness of breath for 30 minutes
• Paramedics reported that an ECG recorded en route to the hospital showed ST-segment elevation in I, aVL, and the precordial leads

Patient 8

• 48-year-old man who develops dyspnea and a productive cough with frothy sputum 72 hours after admission for acute myocardial infarction
• Physical examination shows coarse crackles in both lungs and a blowing, holosystolic murmur heard best at the apex
• ECG shows Q waves in the anteroseptal leads
• Pulmonary capillary wedge pressure is 23 mm Hg

Patient 9

• 24-year-old male graduate student with a 2-month history of repetitive thoughts and anxiety that he is going to be harmed by a stranger on the street
• The anxiety worsened after witnessing a pedestrian getting hit by a car 2 weeks ago
• He says, “That was a warning sign”
• On his way to school, he often leaves an hour early to take a detour and hide from people who he believes might hurt him
• He says his friends are concerned about him but that they do not understand because they were not present at the accident

Patient 10

• 23-year-old woman with strange behavior for the past 6 months
• The father reports that his daughter has increasingly isolated herself in college and received poor grades

Pediatrics - Dermatology

• A skin biopsy shows a normal number of epidermal and follicular melanocytes, suggesting a potential diagnosis that may require a comprehensive eye examination and genetic testing.
• The most likely cause of this patient's condition is a defect in the enzyme tyrosinase (D).

Family Medicine - Osteoarthritis

• A 52-year-old woman presents with a 3-week history of knee pain, worse at the end of the day and when walking.
• Examination shows no tenderness or erythema, but limited range of motion and crepitus.
• The most appropriate next step in management is a weight loss program (B).

Family Medicine - Rheumatology

• A 67-year-old woman presents with bilateral knee pain for the past year, worse with movement and relieved with rest.
• Rheumatoid factor (D) is a potential test to order for this patient.

Surgery - Cirrhosis

• A 44-year-old man presents with increasing fatigue, abdominal distension, and erythema on both palms.
• Laboratory studies show abnormal liver function tests, including elevated total bilirubin and carbohydrate-deficient transferrin.
• The most likely explanation for this patient's thrombocytopenia is cirrhosis (c).

Cardiology

• A 56-year-old man presents with nausea, shortness of breath, and lightheadedness, with an electrocardiogram showing ST-segment elevation.
• The most likely underlying cause of this patient's symptoms is an acute inferior myocardial infarction (e).
• A 54-year-old woman presents with a 2-hour history of nausea and retrosternal chest pain, with an electrocardiogram showing ST-segment elevation.
• The most likely underlying cause of this patient's symptoms is an acute myocardial infarction (ST-segment elevation in leads I, VR), treated with cardiac catheterization and percutaneous coronary intervention.

Dermatology - Skin and Skin Appendages

• A 3400-g newborn presents with pale skin, blond hair, and blue irides, with a defect in the enzyme tyrosinase (D) as the most likely cause of this newborn's condition.
• A 32-year-old man presents with fever, nausea, headache, and confusion, with an enveloped, single-stranded, positive-sense RNA virus.
• The cells most likely affected in this patient's condition are analogous to Langerhans cells (F).
• A 74-year-old man presents with a skin lesion on his right arm, with a biopsy specimen showing carcinoma in situ.
• A 50-year-old woman presents with worsening pain and swelling of her left knee, with Gram-negative diplococci on synovial fluid analysis.
• An x-ray of the affected knee is likely to show joint space narrowing and osteophyte formation.

Gastroenterology - Cirrhosis

• A 65-year-old man presents with progressive abdominal distension and swelling of his legs, with a history of ulcera ve colitis.
• The abdominal findings are most likely caused by increased blood flow in the superior epigastric vein (D).

Medicine - Myocardial Infarction

• A 76-year-old woman presents with a 1-day history of upper abdominal pain, nausea, and dyspnea, with a recent history of an inferior wall myocardial infarction.
• She has a history of type 2 diabetes mellitus and recently diagnosed Alzheimer disease.