Mrs. Smith reports feeling very stiff in the mornings and she often doesn’t begin to feel better until 10:00 or 11:00 a.m. She states recently her hands and wrists ache all the time and are now swollen and hot, which she attributed to her job as a cashier and working additional hours recently, since her husband was recently laid off. Mary is very worried as she can not afford to miss any work with husband laid off, but she feels she is unable to keep up with all of her responsibilities due to her fatigue. She is also helping her 28 year old daughter who just delivered her third baby.
Mrs. Smith’s past medical history reveals the usual childhood illnesses and six uncomplicated pregnancies. She has lost 8 lbs. since her last visit and has mild anemia and an elevated sedimentation rate (ESR). On physical exam, she has some swelling in her joints on both hands. She can extend her fingers to 180 degrees, but cannot make a complete fist with either hand. She has weak grip strength bilaterally and her wrist ROM is limited in all directions. Both of her knees are swollen and flexion is slightly limited. She has a positive bulge sign in the right knee. Diagnostic findings include a negative urine sample, an ESR of 54mm/hr, a C-Reactive protein (CRP) of 8mg/ml, a hematocrit of 30% and positive for rheumatoid factor. Few changes other than soft-tissue swelling are evident on hand and wrist X-rays.
