Level 3: Fatigue – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 26 year old, previously healthy female, who presents to the clinic for evaluation of fatigue and joint pain for 8 weeks. She reports that “I just feel tired all the time and my joints hurt really bad.” She is in no acute distress.

HPI: The patient explains that her joints are “always hurting.” She describes the pain as a 7/10, dull pain that is typically located in multiple joints with bilateral involvement. She states that for the last several days the pain has been especially prominent in her MCP and PIP joints in both hands. She states that these joints always seem very sore and stiff when she wakes up and typically lasts for 2-3 hours before the stiffness subsides. She has also noted that during this time her MCP and PIP joints have become swollen and “feel very difficult to move.” Since her symptoms began, she has begun to notice that she often “feels very tired” regardless of how much sleep she gets. She reports that she just does not have the energy to do what she used to do during the day. She denies any prior occurrence of these symptoms.

PMH: Irritable Bowel Syndrome diagnosed at age 21

SH: Patient works for a local consulting firm. She denies any current or prior use of tobacco. States that she has a glass of wine once a week, but denies any more use than that. Patient reports that she regularly has 3 cups of coffee each day and that she jogs 5 miles 4x a week. She lives alone and is unmarried.

General- Recent low-grade fevers ranging from 99.6-100.8
Abdomen- Patient states that she hasn’t felt like eating for the past couple of weeks. No recent diarrhea, constipation, nausea, or vomiting. No recent abdominal pain.
Musculoskeletal: Reports frequent arthralgias in the past month.

VS- Height 5’8’’, Weight 130lbs, BMI 19.8 HR 60, BP 124/88, RR 12, Temperature 99.7
General Appearance- Patient is cooperative and in no acute distress.
Extremities- Examination of MCP and PIP joints bilaterally reveals swollen joints that are have decreased range of motion and the patient states “feels stiff.” Mild ulnar deviation present in the 2 and 3rd finger bilaterally. Mild decrease in shoulder range of motion bilaterally. All other extremities unremarkable.

Rheumatoid Factor – Positive
Anti-CCP antibody – Positive