Reference no: EM133667825

Question

Ella is 58 year old woman who presents with complaints of pain. She has a history of HTN, Dyslipidemia, Hypothyroidism and Osteoarthritis of L/S spine and Knees. She is in today with complaints of worsening pain. She says that she has been doing well on Tylenol 8 Hour 1-2 twice a day for several years, but it does not seem to be working as it has previously. In regard to her other health issues-she feels she is doing well. When she checks her BP at home, she reports systolic readings of 130-140 and diastolic readings of 70-80. She denies CP or SOB; no myalgias, she is following a low fat or low cholesterol diet. She reports good energy levels and she states she sleeps pretty well. Ella reports that over the last 3-4 months, she has noted more arthritis pain-she says her back and knee pain are still there and for the most part, have not changed. What is new is that she has noted feet, hand and wrist pain. It is worse in the morning, and seems to get better later in the day. She states the Tylenol does not seen to help much with this new pain-and she tells you that she thinks her hands and feet may be swollen from time to time. She denies fever or weigh loss. She has not had any change in medications or any procedures or diagnostics since you saw her last [about 4 months ago]. On Exam today, you see a pleasant well-groomed Hispanic woman in no acute distress. VS: 98.6-76-16 138/76?66 inches tall; 158 pounds Skin/Hair/Nails-you note slight erythema over the MCP joints bilaterally MSK-slight scoliosis of lumbar spine; crepitus of both knees with flexion and extension, but no effusion; full flexion/extension of lower spine, neck, shoulders and elbows. Exam of feet reveals pain with palpation, but no obvious effusion or swelling to feet or ankles; exam of wrists reveals synovitis bilaterally-no redness or warmth is noted and range of motion is normal. On exam of the hands-synovitis is noted to most MCP joints of both hands but none seen on PIPs or DIPs; hand grasps seem to be slightly reduced bilaterally[4/5]. There appears to be slight ulnar deviation on the right. You do not appreciate any other abnormality on the MSK exam. Strength [with exception of the hand grasps] is normal 5/5 bilaterally. Gait and station are normal.