Mrs. Connie Jeans is a 31-year-old married woman with a 12 year old son and a th

Question

Mrs. Connie Jeans is a 31-year-old married woman with a 12 year old son and a thriving career. Connie began having troubles with simple daily life tasks, such as running errands and driving the car. She is experiencing pain in her joints (mostly her feet and hands) and is tiring easily. Her joints are swollen and she reports they are stiff in the mornings. She has also had some recent sinus infections, dry eyes and dry mouth. Today, Connie presents to the clinic where you are working for help.

1.         What questions do you want to ask?

2.         What are possible pathophysiologies that could be happening to Mrs. Jeans? That is—brainstorm as many pathophysiologies as possible for her—and list them here

3.         After developing a list of pathophysiologies, sort them and rank them numerically. Explain your rationales for your choices to be ranked as you chose them.

4.         Test your hypothesis: List the diagnostic tests you would order to confirm or rule out the number one ranked choice.

5.         List at least two assumptions that you are making or testing. (This is hard—what are you taking for granted?) Remember an assumption is something you take for granted. Testing your assumptions can improve your thinking skills.

Explanation / Answer

Ans 1:

Whether she has complaints of joint pains and stiffness affecting both hands and wrists, both feet and knee?

These symptoms are appearing from how many days or weeks?

Does she is having sever pain either in the morning or night. ?

And for how long she is having joint pains?

Does she experience any difficulty in opening jars and holding a toothbrush?

And also to ask the patient about fatigue, fever, weakness, weight loss, malaise and flu-like symptoms?

Ans 2 & 3:

To determine if she has an inflammatory arthritis. Because if the morning stiffness is lasting for several hours and pain in multiple joints which also limits her ability to perform simple activities of daily living with her hands. And if on physical examination if she has synovitis (synovial inflammation tenderness, swelling, warmth, possibly redness, and restricted range of motion) and therefore an inflammatory arthritis or just tenderness in the joints without physical evidence of joint inflammation.

If, synovitis is documented then go for rheumatoid arthritis as the principal diagnosis but keeping in mind about the other diseases like viral arthritis, psoriatic arthritis, polyarticular gout, systemic lupus erythematosus and other connective tissue diseases may present in the same way. The presence of arthralgia alone with or without joint tenderness with no other signs of joint inflammation broadens the differential to include non-inflammatory conditions such as fibromyalgia, joint hypermobility syndrome, and viral arthralgia without arthritis.

If, physical examination shows warmth and swelling on her wrists, knees and the metacarpophalangeal (MCP) (metacarpophalangeal joints are situated between the metacarpal bones and the proximal phalanges) and proximal interphalangeal (PIP) joints of her hands then go for squeeze test of the MCP and metatarsophalangeal (MTP) joints.   

Ans 4: Now, the differential diagnosis at this point?

If, documented the presence of synovitis and therefore, now deal with an inflammatory arthritis. The most likely diagnosis is early rheumatoid arthritis. The symptoms which support this diagnosis are the prolonged morning stiffness and the presence of synovitis in the joints. And the squeeze test of the MCP and MTP joints is a useful screen for early rheumatoid arthritis as synovitis causes the joint capsules to swell and squeezing these inflamed joints together provokes pain as the positive response. These joints are commonly affected in early rheumatoid arthritis.

Ans 5: And if, the patient has experinced fatigue, fever, weakness, weight loss, malaise and flu-like symptoms. Then these are prominent sympyomes of severe rheumatoid arthritis with systemic features, viral arthritis, prodromal hepatitis, SLE and other connective tissue diseases such as polymyositis and a paraneoplastic syndrome.Inflammatory back pain become worse by bed-rest and inactivity and causes early morning awakening and the patient cannot sleep comfortably through the night. And the prominent back symptoms with an inflammatory arthritis will point away from the diagnosis of rheumatoid arthritis. And the presence of a swollen finger or toe indicates psoriatic arthritis instead of rheumatoid arthritis.

Related Questions

Navigate

• Browse (All)
• Browse M
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.