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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


  • Constitutional: Denies fever or chills, denies weight loss
  • Eyes: Denies dry eyes or visual changes
  • ENT: Denies dry mouth
  • Respiratory: Denies difficulty breathing
  • Cardiovacsular: 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.

Question answers should be based on evidence found in readings and from peer-reviewed literature. At least two sources must be used and cited in APA format for each question. Only one source can be a textbook. Resources should generally be within 5 years unless you are explaining the pathophysiology of a disease or providing pertinent background information

Discussion Questions:

  1. Review the symptoms and abnormal physical exam above and review readings from Chapter 45, Alterations of Musculoskeletal functions, and support your interpretation of the most likely diagnosis with evidence.
  2. List all the symptoms from the above that support this diagnosis.
  3. Briefly describe the pathophysiology of the disorder and the impact of environmental and genetic factors on this disorder.

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