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Case Presentation. Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine. Case Presentation.

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case presentation

Case Presentation

Lance C. Brunner M.D.

Assistant Clinical Chief

Department of Family Medicine

case presentation2
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 presentation3
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
case presentation4
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
case presentation5
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
case presentation6
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 presentation7
Case Presentation
  • Next day symptoms come back with a vengeance
  • Now what?
case presentation8
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
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 rheumatica11
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

Differential

Gottron’s sign

in polymyositis

polymyalgia rheumatica13
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