Case #12

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Click here to open your browser's e-mail system. This is where you will record your answers to questions plus any comments you want to pass along to your instructor. After entering your answers, you can check your response by clicking "Faculty Comments".  In the subject line of the e-mail form, enter your name and the name of the case being submitted, i.e., Case #12." When you finish your session with Family Medicine On-line, click the Send button in the e-mail window to forward your answers to your instructor. If you end your session before completing the case, click the Send button to submit your answers, and then exit your browser.

To complete the case during another session, go to the first page of the case and click the link above and then advance to the page where you left off. When finished with this session, click the Send button in the e-mail window. All materials copyrighted 2003 by Penn State University.

If you have completed case L, this is a review. Completion of this case will not be counted toward your assignment.

Chief Complaint

This case scenario assumes you are a family practitioner in a multi-specialty group practice. You have the ability to refer to a wide range of specialists in your practice if you feel it necessary.

Your first patient of the day is Mrs. Hobbley, a friendly 36-year old African-American female, who has been a patient of yours for the last 15 years. She is compliant with her annual check-ups and you last saw her 6 months ago. She presents today because she complains of multiple joint pains in her hands.

 

  1. What is your initial differential diagnosis for this patient's complaint?

Patient History

Given the many possible different causes for the patient's joint pain, let's return to speak to Mrs. Hobbley to refine our differential diagnosis.
  1. What information would be helpful?
  2. What do you think are some possible causes for the patient's rash?
Mrs. Hobbley was in her usual state of good health until 3 months ago. At that time, she noted the gradual onset of a constant, throbbing pain throughout her knuckles bilaterally. She initially noted the pain towards the end of her workday and attributed the pain to her tasks at work. However, the pain would start earlier in the day and would also be present in her wrists. The pain in her wrists started right before spring break and Mrs. Hobbley was hopeful that her family vacation in Disney World would alleviate her pains. While in Orlando, her pain did not improve and she also noted a rash on her face and back after an afternoon at the beach with her family. Since returning from her vacation, the rash on her back has resolved but the facial rash has persisted. She presents to your office today over concern of her persistent joint aches as well as her facial rash.

Allergy: No known drug allergy

Medication: Hydrochlorothiazide 25 mg PO QD

Review of Symptoms: The patient denies dry eyes, dry mouth, Raynaud's phenomenon, hair loss, abdominal pain, jaundice, and chest pain.

Past Medical History: Hypertension diagnosed 8 years ago that is well controlled on her anti-hypertensive medication.

Past Surgical History: Tonsillectomy at age 10

Social History: Mrs. Hobbley is an elementary school teacher who is very proud of her two boys aged 9 and 6. Her husband is a successful corporate attorney at a large law firm. She does not smoke or drink alcohol.

Family History: There is no family history of arthritis, cancer, or heart disease. She has no brothers or sisters. Her parents are both age 75 and are in good health. Her grandmother died at age 55 of a disease that was never diagnosed. Her mother had told Mrs. Hobbley that she had an unusual rash on her face before she died.
 
  1. Prior to the physical exam, what are the 4 most likely possibilities in your differential diagnosis?
  2. What should be included in your focused exam? What specific findings are you looking for?

Physical Examination

Physical exam reveals a well-developed, well-nourished African-American female who appears her stated age.

Vital Signs: BP 145/85 mmHG, RA-sitting; P 80 per minute, regular; RR 16, regular, unlabored; T 36.9o C oral; Ht 157 cm; Wt 65 kg

Skin: Erythematous, confluent, macular eruption involving both cheeks, the bridge of the nose, and the chin with sparing of the nasolabial fold.

HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light with accommodation. Extraocular movements intact. No gross hemorrhages are appreciated. Tympanic membranes clear b/l . Pharynx clear. Moist oral mucosa. Two 1 cm purpuric, necrotic ulcers appreciated on palate.

Neck: Supple, No lymphadenopathy. No masses or bruit.

Lungs: Clear to auscultation bilaterally. No wheezes or rales.

Heart: Regular, Rate and Rhythm without murmur or rub. Normal S1,S2. No S3, S4 appreciated.

Abdomen: Soft, nontender, nondistended. No masses or hepatosplenomegaly.

Musculoskeletal: Increased warmth with tenderness to palpation and pain with active range of motion of wrists, and the 3rd and 4th metacarpo-phalangeal joints bilaterally.

GU/Rectal: Normal female external genitalia. No lesions noted. Normal rectal tone. No masses. Stool: brown. Heme-negative stool.

Neurologic: Cranial nerves II-XII grossly intact. No ataxia. Reflexes 2+ b/l.

  1. What laboratory tests would you like to order?  Remember: Order only those lab tests which will provide information to help obtain an accurate diagnosis. Each test should be ordered with a specific question in mind. A shotgun approach in which every lab test is ordered should be avoided.
  2. What diagnosis most likely accounts for the patient's symptoms?
  3. What is the criteria for the diagnosis of systemic lupus erythematosus?
  4. Would you change the patient's anti-hypertensive medication?
  5. Is ANA a sensitive test for systemic lupus erythematosus?
  6. What other disorders can cause a positive ANA?
  7. Discuss the sensitivity and specificity of anti-double-stranded DNA antibodies and anti-Smith (SM) antibodies for the diagnosis of SLE.
  8. Should a renal biopsy be performed?
  9. What non-pharmacologic therapy should be offered to patients with SLE?
  10. What pharmacologic therapy is advocated?
  11. How should the patient's rash be treated?

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This page was last updated on April 24, 2006
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