Musculoskeletal Case Study:
A 30 year old Latino woman presents for evaluation of wrist pain and swelling. She developed symptoms about 3 months ago and has noted progressive worsening since that time. In addition, she
...
Musculoskeletal Case Study:
A 30 year old Latino woman presents for evaluation of wrist pain and swelling. She developed symptoms about 3 months ago and has noted progressive worsening since that time. In addition, she has tenderness across the balls of her feet with any weight bearing. The pain is worse when she is inactive and improves with activity. The symptoms have significantly affected her ability to perform her job as a receptionist in a busy office. She denies any recent trauma to her hands or feet or other joint pain.
She reports stiffness in the feet and ankles as well as 4 hours of overall morning stiffness that improves only marginally for the rest of the day. She has noted increased fatigue and weakness in activities significantly. She does not recall being bitten by any insects recently.
PMH: Non-contributory
SH: Receptionist, single, barely supports herself without assistance from close by family. Denies smoking history, social drinker on the weekends with friends.
Medications: Birth control pills and MV
ROS:
Constitutional: Denies fever or chills, denies weight loss
Eyes: Denies dry eyes or visual changes
ENT: Denies dry mouth
Respiratory: Denies difficulty breathing
Cardiovascular: Denies chest pain
Genitourinary: Denies bladder changes
Gastrointestinal: Denies any bowel changes
Endocrine: Denies polyuria, polydipsia, or polyphagia
Musculoskeletal: Denies neck or shoulder stiffness
Skin/Integument: Denies rashes, lesions, ulcers, changes in hair, skin or nails
Physical Exam:
General: Appears in no acute distress
Vitals: 110 lbs, height 63 in., temp orally of 100 degree F, BP is 120/70. HR 64. RR 12 and regular.
All other exam findings normal except:
Neuromuscular: There is moderate synovitis (swelling) of the MCP and PIP joints bilaterally and of the MTP joints bilaterally. The patient has limited ROM of the UE and LE digits due to the pain. There are no nodules noted on any extremities. The Phalen’s, Finkelstein’s, and Tinel’s tests are negative. There is no warmth or redness of any joint. DTR’s are 2+ throughout.
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