Presentation on theme: "Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine."— Presentation transcript:
Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine
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.
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
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
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
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….
Case Presentation Next day symptoms come back with a vengeance Now what?
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….
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
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
Differential Occult infection RA Hypothyroidism Endocarditis Fibromyalgia Polymyositis OA Malignancy and paraneoplastic syndromes Bursitis Tendinitis Vasculitis Gottron’s sign in polymyositis
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