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Morning Report

DWIGHT PARKER
10/22/18
 16 yo female presenting with 10
days of diffuse joint pain, swelling of
her hands, feet, and face, other
“swollen joints” and intermittent
rash
HPI
 Previously healthy
 10 days of bilateral PIP joints, wrists, elbows, shoulders, feet, ankles,
knees, hips, neck and back pain and possible swelling. Has now
been to the ED 4 times and treated with steroids and
antihistamines
 5 days ago began experiencing intermittent rash (started after
lying on some grass), large welts appearing first on her back and
side. Now affecting her palms, soles, scalp, and body. Has been
taking occasional doses of benadryl and loratadine with no
improvement. Very itchy. Some itchy eyes. No bleeding, bullae, or
ulcerations
 3 days ago got severe lip swelling but no respiratory symptoms. Got
better.
 Yesterday got shortness of breath, felt like her heart was beating
quickly, and felt burning in her chest
 Has been seen in the ED 4 times in the past 5 days
 Evaluated by rheumatology today who recommended she be
admitted for further workup
 PMHx: “Healthy.” No PCP.
 Hospitalized once at age 7 for an episode of swollen feet and
rash that resolved after 3 days, no diagnosis
 PSHx: No prior surgeries
 Meds: No regular prescribed medications. During the past
week has received:
 Naproxen as needed, IV Benadryl, Famotidine,
Methylprednisone (125 mg x2), and Prednisone (40 mg x4 at
home)
 Allergies: NKDA. No known food or environmental allergies
 FHx: Parent with history of rheumatoid arthritis.
 SHx: Recently spent 6 months living in central Mexico recieved
tattoos at the local parlor before she came back to the
states.
 ROS: as above
Exam
 General: Alert and oriented, well nourished, no acute distress;
quiet

 Eye: PERRL, EOMI, normal conjunctiva; “normal” funduscopic exam


HENT: erythematous, swollen cheeks and nose (does not spare
nasolabial folds), NC, clear tympanic membranes, normal hearing,
moist oral mucosa, no scleral icterus
Neck: tender to palpation of spine; some tenderness along
paraspinal muscles as well; supple, no JVD, no lymphadenopathy

 Lungs: no wheezes, crackles, stridor; good air flow bilaterally, non-


labored respiration

 Heart: Normal rate, regular rhythm, no murmur or edema

 Abdomen: Soft, non-tender, non-distended, bowel sounds present,


no masses
Musculoskeletal:
- range of motion is diminished in some joints secondary to pain but
able to range fully when pressed
- knees, wrists, MCP, PIP, neck, hip, shoulder joints tender to palpation
bilaterally
- knee, wrist, PIP and MCP joints swollen bilaterally
- knee joints warm to touch bilaterally
- slight tenderness in muscles throughout, but pain more so at tendon
insertions
- joints without erythema
Skin:
Flat, red macules present in between fingers, on palms, and on back;
no scale with rash; currently no raised lesions; Skin is warm, dry and well
perfused
- no signs of pitting on nails

Neurologic: Awake, alert, and oriented X3, CN II-XII normal


Psychiatric: Cooperative, appropriate mood and affect
Labs
Sodium Level: 141 mmol/L
Potassium Level: 3.6 mmol/L
Chloride Level: 107 mmol/L
CO2: 23 mmol/L
Anion Gap (Na Cl CO2): 11
mmol/L
WBC: 14.4 K/mcL Glucose Level: 161 mg/dL
RBC: 4.8 x10^6/mcL High
Hemoglobin: 14.5 g/dL BUN: 9 mg/dL
Hematocrit: 41.1 % Creatinine Level: 0.59 mg/dL
Estimated Creatinine
Neutrophil 90.8 %
Clearance: 119 mL/min
Lymphocyte 7.6 %
Calcium Level: 10.1 mg/dL
Monocyte 1.3 % Protein Total: 8.6 g/dL High
Eosinophil 0 % Albumin Level: 4.8 g/dL
Basophil 0 % Bilirubin Total: 0.7 mg/dL
Alk Phos: 74 unit/L
AST: 32 unit/L
ALT: 59 unit/L
Labs
Lactic Acid, Plasma (Venous): SSA (Ro) Ab: Negative: <0.2
2.4 mmol/L
SSB (La) Ab: Negative: <0.2
HCG, Beta Quantitative: <2
Scl-70 Ab: Positive: 2.1 (ELISA)
ANA Screen: Positive
(ELISA)/Negative (IFA)
Jo-1 Ab: Negative: <0.2

dsDNA Ab: Negative: <0.2 Centromere Ab: Negative:


<0.2
RNP Ab: Negative: <0.2
Ribosomal P Ab: Negative: <0.2

Sm Ab: Negative: <0.2 Chromatin Ab: Negative: <0.2

Rheumatoid Factor: <15


Labs/Micro

GC/CT negative
HLA-B27 normal
RPR negative
HepBSAB, HepBcAB, HepBsAg, HepCAB all neg
aldolase, IgM, IgA, IgE, IgG, vWF, Cryoglobulin, EHEC
toxin, Stool culture, urine culture all negative/normal
Discuss!

 Email Dwight.Parker@hsc.utah.edu with any


questions or discuss over lunch