Department of Medicine Grand Rounds Clinical Vignette April 15, 2009 Michael Owen, PGY 2

Chief Complaint A 55 year old female presented to clinic for routine follow-up. A 55 year old female presented to clinic for routine follow-up.

HPI The patient reported morning stiffness and pain in her bilateral MCP, PIP, wrist, knee, and ankle joints for the past 2 months. The patient reported morning stiffness and pain in her bilateral MCP, PIP, wrist, knee, and ankle joints for the past 2 months. The symptoms improved with Acetaminophen and Ibuprofen, which she was taking daily. The symptoms improved with Acetaminophen and Ibuprofen, which she was taking daily. Occasionally, she required tramadol as well to control the pain. Occasionally, she required tramadol as well to control the pain.

Additional History Past Medical History: –Rheumatoid arthritis (diagnosed at age 19) –Hypertension –Mixed hyperlipidemia –Mild intermittent asthma Past Surgical History: –Cholecystectomy Family History: –Aunt with rheumatoid arthritis –Father had myocardial infarction at age 60 Social History: –Married with three adult children –Works as elementary school teacher –Rare alcohol use –Smoked ½ pack per day for 20 years, quit 15 years ago

Additional History Allergies: No known drug allergies Medications: –Ibuprofen 600 mg 3 x per day –Acetaminophen 650 mg q6 hrs PRN pain –Methotrexate 7.5 mg weekly –Tramadol 50 mg q6 hrs PRN pain –Albuterol inhaler PRN wheezing –Hydrochlorothiazide 25 mg daily –Simvastatin 40 mg daily

Physical exam General: overweight female in no acute distress General: overweight female in no acute distress Vitals: T: 98.8 BP: 132/85 HR: 72 RR: 16 BMI: 29 Vitals: T: 98.8 BP: 132/85 HR: 72 RR: 16 BMI: 29 MCP and PIP: warmth and swelling with tenderness on palpation, no deformity MCP and PIP: warmth and swelling with tenderness on palpation, no deformity Wrist, knee, ankle: mild tenderness Wrist, knee, ankle: mild tenderness The remainder of the physical exam was normal

Labs Rheumatoid factor: positive Rheumatoid factor: positive anti-CCP: positive anti-CCP: positive Total cholesterol: 190 Total cholesterol: 190 LDL: 88 LDL: 88 HDL: 43 HDL: 43 Triglyceride: 289 Triglyceride: 289

Imaging Xray of hands: no evidence of erosion or cartilage loss Xray of hands: no evidence of erosion or cartilage loss

Working Diagnosis Rheumatoid Arthritis Rheumatoid Arthritis Hypertriglyceridemia Hypertriglyceridemia

Case Follow Up The patient was counseled on weight loss The patient was counseled on weight loss It was recommended that she start taking omega 3 fatty acid supplements (fish oil) for high triglycerides It was recommended that she start taking omega 3 fatty acid supplements (fish oil) for high triglycerides

Case Follow up Three months later, the patient reported less joint pain and less use of tramadol for breakthrough pain Three months later, the patient reported less joint pain and less use of tramadol for breakthrough pain Repeat lipid panel showed Repeat lipid panel showed Total cholesterol: 180 Total cholesterol: 180 LDL: 93 LDL: 93 HDL: 55 HDL: 55 Triglyceride: 157 Triglyceride: 157

Final Diagnosis Rheumatoid Arthritis Rheumatoid Arthritis Hypertriglyceridemia Hypertriglyceridemia