Course Case Studies
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Patient A is a woman, 29 years of age, with two small children. She presents to her primary care provider with complaints of rashes developing on her arms and legs whenever she spends time in the sun. She also reports several small patches of hair loss on her head that she attributes to the stress of new motherhood and to a recent trip and her fear of flying. She reports a lack of energy, being easily fatigued, and always needing to nap during the day. Patient A also reports mild pain in her fingers and elbows but attributes the joint discomfort to caring for the children. She states that these problems have been ongoing for approximately four months.
Patient A has no known allergies and takes no prescription or over-the-counter medication aside from occasional naproxen for joint pain and antacid for heartburn. She neither smokes nor drinks alcohol. Her youngest child is 2 years of age, and she reports unremarkable childbirths and postpartum periods. Aside from the current complaints, the patient's medical history is unremarkable.
She has four brothers and three sisters. The family history indicates an older sister with rheumatoid arthritis, an aunt with pernicious anemia, and mother with hyperthyroidism.
The primary care provider conducts a full physical assessment (Table 2). Several laboratory tests are ordered, with the following results:
Hematocrit (HCT): 23%
Red blood cell (RBC) count: 3.5 million cells/mcL
White blood cell (WBC) count: 5,500 cells/mcL
Platelets: 350,000 cells/mcL
ESR: 25 mm/hour
Urinalysis: Normal
ANA: 1:640
Anti-DNA antibody test: Elevated
Complement assay: Decreased C3 level at 43 mg/dL and decreased C4 level at 14 mg/dL
PATIENT A'S FIRST PHYSICAL EXAM RESULTS
| Parameter | Findings | ||||
|---|---|---|---|---|---|
| General appearance |
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| Skin and nails |
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| Head and nose |
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| Eyes |
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| Ears | Tympanic membranes intact | ||||
| Neck |
| ||||
| Chest |
| ||||
| Abdomen |
| ||||
| Extremities |
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| Genitourinary system | Normal female | ||||
| Neurologic status |
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| Cardiovascular system |
| ||||
| Vital Signs | |||||
| Blood pressure | 110/70 mm Hg | ||||
| Temperature | 99.8° F | ||||
| Heart rate | 70 beats per minute with regular rhythm | ||||
| Respiratory rate | 15 breaths per minute | ||||
Further, a tissue biopsy of one of the lesions is taken and reveals vasculitis (i.e., white blood cells within the walls of blood vessels).
Based on the results of the assessment and laboratory studies, Patient A is diagnosed with SLE.
A one-month course of prednisone with tapered doses is prescribed. Nabumetone, an anti-inflammatory, is added to the regimen prior to the prednisone being weaned off. After one month of treatment, all signs and symptoms of lupus have resolved.
However, 13 years later, Patient A again presents to her primary care provider, this time with complaints of a productive cough and transient stiffness and pain in her hands and feet (migratory polyarthritis). She is afraid that she is developing rheumatoid arthritis like her sister. The provider conducts a physical examination (Table 3) and is concerned that the patient may be showing signs of pneumonia. A chest x-ray revealed mild pulmonary edema but no white blood cell infiltrates in the terminal airways. Laboratory tests reveal:
HCT: 43%
Platelet: 330,000 cells/mcL
WBC count: 1,200 cells/mcL
Urinalysis: Within normal limits
PATIENT A'S SECOND PHYSICAL EXAM RESULTS
| Parameter | Findings | |||
|---|---|---|---|---|
| General appearance |
| |||
| Skin and nails | No lesions or abnormalities noted | |||
| Head and nose |
| |||
| Eyes |
| |||
| Ears | Tympanic membranes intact | |||
| Neck |
| |||
| Chest |
| |||
| Abdomen |
| |||
| Extremities |
| |||
| Genitourinary system |
| |||
| Neurologic status |
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| Cardiovascular system |
| |||
| Vital Signs | ||||
| Blood pressure | 140/90 mm Hg | |||
| Temperature | 100.0° F | |||
| Heart rate | 105 beats per minute with regular rhythm | |||
| Respiratory rate | 15 breaths per minute | |||
Patient A is diagnosed as experiencing a lupus flare and is prescribed a one-month course of prednisone along with a 10-day course of antibiotics to prevent pneumonia. Within three months, all signs and symptoms have resolved.
Five years later, Patient A returns to her primary care provider complaining of fatigue, anorexia, weight loss (25 pounds in the last four months), and significant swelling in her abdomen, face, and ankles. The nurse practitioner notes a "butterfly-shaped" rash present across the bridge of the patient's nose and cheeks. Blood tests reveal an HCT of 24% and a WBC count of 2,400 cells/mcL. A dipstick examination of the urine reveals an abnormal protein concentration, and microscopy indicates the presence of significant numbers of red and white blood cells. A 24-hour urine protein collection reveals excretion of 2.5 g protein in 24 hours.
What is the significance of the patient's family history?
Is this patient underweight, normal weight, overweight, or obese?
What underlying pathologic process is responsible for Patient A's hair loss? What is the relevance of the abnormal ESR?
Vasculitis in lupus results from the trapping of antigen antibody complexes in blood vessel walls followed by an intense inflammatory response to the immune complexes. Why is prednisone effective in relieving vasculitis?
What is the most likely cause of jaundice in this patent?
What pathophysiology underlies lymph node enlargement in this patient?
The patient's WBC differential was: 75% neutrophils, 15% lymphocytes, 5% monocytes/macrophages, 4% eosinophils, and 1% basophils. Which one of these white blood cell types has been specifically targeted by the patient's immune system?
Why was Patient A experiencing swelling throughout her body?
Patient A is a woman, 29 years of age, with two small children. She presents to her primary care provider with complaints of rashes developing on her arms and legs whenever she spends time in the sun. She also reports several small patches of hair loss on her head that she attributes to the stress of new motherhood and to a recent trip and her fear of flying. She reports a lack of energy, being easily fatigued, and always needing to nap during the day. Patient A also reports mild pain in her fingers and elbows but attributes the joint discomfort to caring for the children. She states that these problems have been ongoing for approximately four months.
Patient B is a woman, 35 years of age, who has worked as a housekeeper for the past 10 years. She is 5 foot 3 inches in height with a weight of 178 pounds. She presents to her primary care provider with complaints of low back pain. She reports having had this pain intermittently for several years; however, for the past two days, it has been worse than ever. The recent exacerbation started after vacuuming a rug (i.e., pulling and twisting at the waist). Patient B reports that the pain is primarily on the right lower side and radiates down her posterior right thigh to her knee; it is not associated with any numbness or tingling. The pain can be relieved by lying flat on her back with her legs slightly elevated and is lessened somewhat when she takes ibuprofen 400 mg. Except for moderate obesity and difficulty maneuvering onto the examination table because of pain, the patient's examination is fairly normal. The only abnormalities noted are a positive straight leg raise test, with raising the right leg eliciting more pain than the left. Her strength, sensation, and deep tendon reflexes in all extremities are normal.
Patient C is a woman, 50 years of age, who presents to her primary care provider for her annual exam. She reports having been very tired for the past month and also experiencing stiffness, pain, and swelling in multiple joints. She states, "I ache all over, and I have pain in different places all the time. One day it is in my right shoulder, the next day in my right wrist, and the following day my left wrist. I'm stiff everywhere when I get up in the morning or if I sit for any length of time. And I feel so tired, like I have a case of the flu that won't go away."
The patient has been diagnosed with hypothyroidism in the past, for which she is taking levothyroxine. She is also prescribed venlafaxine to treat major depressive disorder, and she indicates that her mood has been good, despite the fatigue. She is also taking an over-the-counter multivitamin and calcium supplement. Patient C reports rarely using alcohol and never smoking. There is no family history of autoimmune disorders.
The primary care provider does a complete physical exam (Table 4) and orders laboratory tests. The laboratory blood test results are:
Sodium: 140 meq/L
ANA: Negative
HCT: 43%
Uric acid: 2.9 mg/dL
Potassium: 3.7 meq/L
ESR: 38 mm/hour
WBC count: 15,100 cells/mcL
Cholesterol: 189 mg/dL
Chloride: 104 meq/L
Creatinine: 1.0 mg/dL
Platelets: 270,000 cells/mcL
Albumin: 4.0 g/dL
Bicarbonate: 23 meq/L
Blood glucose: 94 mg/dL
RBC count: 4.7 million cells/mcL
Thyroid stimulating hormone (TSH): 1.7 mcU/mL
Blood urea nitrogen: 18 meq/L
Hemoglobin: 14.9 g/dL
Calcium: 8.8 mg/dL
Rheumatoid factor: Positive
PATIENT C'S PHYSICAL EXAM RESULTS
| Parameter | Findings | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| General appearance |
| ||||||||
| Skin and nails |
| ||||||||
| Head and nose | Head atraumatic | ||||||||
| Eyes |
| ||||||||
| Ears | Tympanic membranes intact | ||||||||
| Neck |
| ||||||||
| Chest |
| ||||||||
| Abdomen |
| ||||||||
| Extremities |
| ||||||||
| Genitourinary system |
| ||||||||
| Neurologic status |
| ||||||||
| Cardiovascular system |
| ||||||||
| Vital Signs | |||||||||
| Blood pressure | 125/80 mm Hg | ||||||||
| Temperature | 100.0° F | ||||||||
| Heart rate | 80 beats per minute with regular rhythm | ||||||||
| Respiratory rate | 15 breaths per minute | ||||||||
A urinalysis is performed and is normal, with no RBCs, WBCs, or protein. A chest x-ray finds no fluid, masses, infection, or cardiomegaly. An x-ray of the hand shows soft tissue swelling and bone demineralization but no erosions. Synovial fluid removed from the left knee (7.4 mL) is cloudy and pale yellow in appearance; analysis indicates 14,000 white blood cells/mcL (primarily neutrophils) and a glucose level of 60 mg/dL.
Based on these findings, Patient C is diagnosed with rheumatoid arthritis and referred to a rheumatologist for follow-up.
Which of Patient C's vital signs is consistent with a diagnosis of rheumatoid arthritis and why?
Are there any other abnormal findings from the patient's physical exam that are consistent with a diagnosis of rheumatoid arthritis?
What is the association between the fixed nodules at pressure points on the left wrist/right elbow and a diagnosis of rheumatoid arthritis?
Why is it reasonable that this patient has no stiffness, pain, or swelling in the DIP joints of the fingers?
Which of these patient's laboratory test results are consistent with a diagnosis of rheumatoid arthritis?
In terms of the progression of the disease, what do the results of the hand x-ray suggest?
Which findings in the examination of the synovial fluid are consistent with a diagnosis of rheumatoid arthritis?
What causes limitation of joint motion that occurs early in the clinical course of rheumatoid arthritis? What causes limitation of joint motion that occurs late in the clinical course of rheumatoid arthritis?
- Back to Course Home
- Participation Instructions
- Review the course material online or in print.
- Complete the course evaluation.
- Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.