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

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. Specialties Critical Case Study

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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!

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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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?

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 525 Posts

Specializes in Oncology, Home Health, Patient Safety.

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, ADN, LPN, RN

1 Article; 922 Posts

Specializes in Mental health, substance abuse, geriatrics, PCU.

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

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. 

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 525 Posts

Specializes in Oncology, Home Health, Patient Safety.
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.

Patient Safety Columnist / Educator

SafetyNurse1968, ADN, BSN, MSN, PhD

61 Articles; 525 Posts

Specializes in Oncology, Home Health, Patient Safety.
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.

Specializes in Community health.

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

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, ADN, LPN, RN

1 Article; 922 Posts

Specializes in Mental health, substance abuse, geriatrics, PCU.
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, BSN

451 Posts

Specializes in ED, med-surg, peri op.

I think I have the answer!!

I would want to check kidney function. 

Oh and a chest X-ray 

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