Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine.
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Transcript of Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine.
![Page 1: Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine.](https://reader036.fdocuments.in/reader036/viewer/2022082816/56649cce5503460f9499a270/html5/thumbnails/1.jpg)
Case Presentation
Lance C. Brunner M.D.Assistant Clinical ChiefDepartment of Family Medicine
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Case Presentation
82 yo male with type II DM and multi-infarct dementia presents to the ER with a 3 week history of worsening ability to walk, difficulty getting out of bed, leg spasms, and just general deconditioning. Daughter states that patient also has had decreased appetite, low grade fevers, and worsening depression.
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Case Presentation
PMHX Type II DM HTN Excessive alcohol
intake – none for the last year
Multi-infarct dementia
PSHX None
Allergies None
Meds ASA Prinzide Simvastatin
FHx DM CAD
SHX Widowed Lives with daughter
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Case Presentation
PE Gen – crying,
complaining of bilateral hip, lower back, and thigh pain, moderate distress
99.2 104 16 148/66 Neck – supple CV – RRR Lungs – dry crackles
Abd – soft + bs Ext – TTP of
paraspinal lumbar region, bilateral thighs, bilateral shoulders, moderate pain with back flexion
Neck - +paraspinal tenderness. Supple
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Case Presentation
L/S x-ray mild OA/DDD
UA negative WBC 10.0 with
normal diff Plt 520 HB 13.2 Chem 7 normal SGPT 35
Total CK 123 CT back negative CXR negative CT head negative EKG LVH no acute
changes Troponin I <0.1
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Case Presentation
Neurology called for formal consult Patient diagnosed with diffuse
myalgias likely statin related with dehydration
Hydration and MS given in the ER DC statin Vicoden given F/U pcp….
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Case Presentation
Next day symptoms come back with a vengeance
Now what?
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Case Presentation
Upon further questioning, daughter describes patient with significant muscle stiffness of the shoulders and thighs and difficulty getting out of a chair. Leg spasms still persist at night….
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Case Presentation
ESR 103
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Polymyalgia Rheumatica
Aching and morning stiffness in the girdle Subacute or acute Generally symmetric Malaise, fatigue, anorexia, low grade fever, weight
loss 10% of patients with PMR have Temporal Arteritis
(TA) 50% of patients with TA have PMR
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Polymyalgia Rheumatica
Physical Exam Decreased rom of shoulders and hips Normal strength Muscle tenderness often not a prominent
feature – tenderness usually due to bursal involvement
Age > 50, ESR >50, although sedimentation rate can be normal in up to 22% of patients
Elevated CRP (may be more sensitive) Elevated IL6 levels may be related to disease
activity in TA
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Differential
Occult infection RA Hypothyroidism Endocarditis Fibromyalgia Polymyositis OA Malignancy and
paraneoplastic syndromes
Bursitis Tendinitis Vasculitis
Gottron’s signin polymyositis
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Polymyalgia Rheumatica
Treatment Prednisone 10-20 mg a day (40mg-80 daily at
if temporal arteritis is present) with subsequent taper
Always be on the lookout for temporal arteritis (temporal artery tenderness, headache, jaw pain, visual loss, and evidence of non-cranial ischemia)
Relapse 25-50% MTX a consideration if patients at high risk of
glucocorticoid side effects