Case Study: Joint Pain, Rash, Hair Loss - What's Going On?

Updated | Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

A new case study in which R.W. presents to her PCP with a cough, mild fever, joint stiffness and pain and a history of rashes, anemia and hair loss.

Can you figure out the diagnosis?

Case Study: Joint Pain, Rash, Hair Loss - What's Going On?

Chief Complaint

R.W. is a married, 34-year-old Hispanic female with two young children who presents to her primary care provider with a productive cough, stiffness and pain in her hands and feet that comes and goes. She states, “It moves around from joint to joint. I’m worried I’ve got RA like my sister.” Her PCR test for COVID-19 has come back negative.

History of Present Illness

Five years ago, R.W. went to her PCP after four months of rashes that appeared on her arms and legs whenever she went into the sun. She had lost several small patches of hair on her scalp and stated she thought it was related to stress. She also complained of fatigue that required her to take daily naps. She had mild arthritic pain in her fingers and elbows but thought it was related to aging. A tissue biopsy of one of the multiple rash-like lesions from her arm revealed vasculitis (white blood cells within the walls of blood vessels). Her CBC indicated mild anemia, but microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape size and color, ruling out iron, folate and vitamin B12 deficiencies. A two-month course of prednisone caused all signs and symptoms to resolve.

Past Medical History

Unremarkable, current with all vaccinations including influenza.

Family History

She has two brothers and one sister. Her older sister has rheumatoid arthritis, and an aunt has pernicious anemia. Her mother has Graves’ disease.

Social History

No smoking or drinking

Medications

Naproxen for joint pain, antacid for heartburn, no other over the counter drugs

Allergies

NKA

Vital Signs

  • BP 141/90 sitting, RA
  • HR 105
  • RR 20
  • T 100o F
  • HT 5’6”
  • WT 105 lbs

Review of Systems (only abnormal values presented)

  • Skin: Slight jaundice 
  • HEENT: yellowing of the sclera
  • Lungs/Thorax: Auscultation reveals abnormal lung sounds
  • Musculoskeletal: joint stiffness and pain
  • Immune: enlarged axillary and inguinal lymph nodes  

Questions

What is causing the lung symptoms, jaundice, joint stiffness and pain?

What happened 5 years ago?

Imagine you only get 5 questions. What information should you ask for that will give you the most information for a diagnosis?

What labs do you want?

What other diagnostic tests should we run?

Ask me some questions!

If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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68 Comment(s)

crosstrainer878

crosstrainer878

2 Posts

I will bite! I have a disorder in mind, and an alternate. So here goes for my question(s).

1.  What was/is her sexual history (now she is married)?

2. What is her occupation?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

She’s been married for 10 years to the same man, prior to that two partners-no history of STDs. She sells real estate for a large real estate company. Thanks for playing -I can’t wait to see what you guessed!

TheMoonisMyLantern

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 15 years experience. 1 Article; 922 Posts

So, I'd want to run a CMP with special attention to her liver enzymes, I'd also be curious as to her glucose level and bun/creat., I'd also want an ESR and I would really like an ANA to be done. TSH, T3 and T4, I might go ahead and order a cortisol level, just out of curiosity especially depending on the results of her CMP. Chest x-ray due to the abnormal lung sounds, fever, and slight tachycardia. Depending on those results she may need follow up with a CT scan. And what's going on with that liver? I would probably want an ultrasound.

Has she had any dramatic fluctuations of weight during the past five years?

Did she ever travel outside of the country prior to her initial episode?

Any urinary symptoms?

I'm seeing a lot of inflammation with her situation, but I'm keeping endocrine problems and malignancies in mind as well.

d'cm

d'cm

282 Posts

let's do an ELISA test. 

I think I would want cmp, sputum for afb, cxr, ana, esr, thyroid panel, and hiv testing

I would ask about travel outside the US, dx from pcp 5 years ago, has joint pain been happening for the past 5 years, last time she had a rash, anyone in the family with similar sx especially productive cough. 

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

On 12/22/2020 at 11:20 AM, TheMoonisMyLantern said:

So, I'd want to run a CMP with special attention to her liver enzymes, I'd also be curious as to her glucose level and bun/creat., I'd also want an ESR and I would really like an ANA to be done. TSH, T3 and T4, I might go ahead and order a cortisol level, just out of curiosity especially depending on the results of her CMP. Chest x-ray due to the abnormal lung sounds, fever, and slight tachycardia. Depending on those results she may need follow up with a CT scan. And what's going on with that liver? I would probably want an ultrasound.

Has she had any dramatic fluctuations of weight during the past five years?

Did she ever travel outside of the country prior to her initial episode?

Any urinary symptoms?

I'm seeing a lot of inflammation with her situation, but I'm keeping endocrine problems and malignancies in mind as well.

I will post lab/radiologic/UA results on Saturday, I will go ahead and tell you her CMP is WNL and her thyroid panel is negative. Weight at most recent annual doctor’s visit 8 months ago: 120 lbs. No travel outside country.

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience. 81 Articles; 522 Posts

22 hours ago, MelissaPendergraft said:

I think I would want cmp, sputum for afb, cxr, ana, esr, thyroid panel, and hiv testing

I would ask about travel outside the US, dx from pcp 5 years ago, has joint pain been happening for the past 5 years, last time she had a rash, anyone in the family with similar sx especially productive cough. 

No other family with similar symptoms, no travel outside US, Dx from PCP 5 years ago focused on fatigue and stress. The rash was attributed to stress/ possible allergic reaction to sunscreen (they took a wait and see approach and she's not been back with any problematic symptoms until now). She has had mild joint pain on an off, but so mild she just treated it with Naproxen.

CommunityRNBSN

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 4 years experience. 831 Posts

I hate all these case studies because they make me feel like a complete idiot. ?

magellan

magellan

84 Posts

Yes and she doesn't want us to reveal the answer which we know. We are nurses and professionals so our views and opinions should matter or else patients outcome will be  six feet below the ground.

TheMoonisMyLantern

TheMoonisMyLantern, ADN, LPN, RN

Specializes in Mental health, substance abuse, geriatrics, PCU. Has 15 years experience. 1 Article; 922 Posts

4 hours ago, CommunityRNBSN said:

I hate all these case studies because they make me feel like a complete idiot. ?

You're not alone, but I do enjoy them they can be helpful to learn about less common conditions and I really like seeing what other people would do, it's very helpful. Often I'll read and be like "Wow, why didn't I think of that?". 

EDNURSE20

EDNURSE20, BSN

Specializes in ED, med-surg, peri op. Has 5 years experience. 451 Posts

I think I have the answer!!

I would want to check kidney function. 

Oh and a chest X-ray