Presenting Complaint
History of Presenting Complaint
An 88-year-old lady was admitted to our hospital suffering with polyarthralgia. She was in her usual state of apparent good health until two months prior to admission when she developed left anterior lower leg pain when walking.
# Left anterior lower leg pain
# Fever developed, up to 38 C˚
Two weeks prior to admission, she developed fever of between 37-38 C˚ associated with rigors. However, she still had an r appetite and could sleep normally. She saw a local doctor and blood examinations revealed an elevation of CRP of 7.96 mg/dL without leukocytosis.
# rigors
ブランチ先生コメント;米国ではshaking chillと表します。
井上コメント;寒気は3段階で評価します。単に寒い、布団をかければ大丈夫、布団をかけても寒い、の3段階で布団をかけても寒い、をshaking chillとし菌血症の疑いが濃くなる所見となります。ない、よりもshaking chillを有する場合、odds ratio は4倍強といわれています。
# elevation of CRP and ESR
The doctor could not make a diagnosis and suggested her to watch and wait. However, she developed swelling of her left ankle, and she consulted the department of general internal medicine in our hospital.
# swelling of left ankle
# Hypertension
At that time, she was afebrile (36.9 C˚), her blood pressure was 154/88 mmHg, heart rate was 73 beats per minutes, and respiratory rate was 14 times per minutes. Her blood examinations revealed an elevated C-reactive protein of 7.96 mg/dL, an erythrocyte sedimentation rate of 100 mm/hr. without leukocytosis. Her lower leg X-ray appeared normal. She was prescribed celecoxib 400 mg twice daily for one week, for suspected pseudogout. In fact, she did not improve, and she developed polyarthralgia of her metacarpal phalangeal (MCP) joints on her right index and middle fingers, bilateral ankles, and her right shoulder. In this two or three weeks, her activities of daily living gradually worsened. She experienced difficulty walking and was unable to grasp a pot or knife when cooking. She was admitted to our hospital for further examination. 
# Decreased ADL
Past Medical History
60’s: Hypertension
81 years old: Contact dermatitis
81 years old: Chronic pigmented purpura
81 years old: Gallstones
82 years old: Spinal canal stenosis at L4/5 level
83 years old: Hashimoto’s disease with hypothyroidism
84 years old: Osteoporosis
85 years old: Suspected left rotator cuff tear.
87 years old: Pyelonephritis
Medication (on admission)
Azilsartan 10 mg, once daily
Levothyroxine 37.5 μg, once daily
Mecobalamin 1500 μg, once daily
Sennoside 12 mg, once daily
Pregabalin 150 mg, two times daily
Alendronate 35 mg, once weekly
Hirudoid 0.3% 25g
Betamethasone 0.12% 5g
Betamethasone 0.05% 5g
Dexamethasone 0.1% 10g
ブランチ先生コメント;このmedication listは現病歴に合うでしょうか?なぜこの薬物を服薬しているか確認することはとても重要です。服用歴から既往歴が修正され現病歴をよりこまかく記載できるきっかけになるからです。ブランチ先生コメント;コバラミンはよく整形外科医が処方します。リリカもよく処方されている薬になりますが昨年NEJMではエビデンスを証明することはできませんでした。https://www.nejm.org/doi/full/10.1056/NEJMoa1614292
Family history
FatherAsthma, acute myocardial infarction
DaughterBreast cancer
Social History
Tobacco20’s~30’s, five cigarettes daily
Alcohol: 2-3 times a week, a glass of beer (about 8 grams of pure alcohol per a week)
Allergy: No food, drug, or other allergies
She lives with her daughter.
Travel History
Review of Systems
General: No night sweats.
HEENT: No headaches, dizziness, rhinorrhea, toothaches, sore throat, neck stiffness, or neck swelling. No change in vision or hearing.
Cardiovascular: No palpitations, chest pain, or syncope.
Respiratory: No sputum, or hemoptysis. No tuberculosis contacts or previous exposure.
Gastrointestinal: No vomiting, nausea, anorexia, constipation, melena, or abdominal pain.
Renal and Urological:No dysuria, residual sensation of urine, or nocturia.
Endocrine: No heat or cold intolerance, polydipsia or polyphagia, or diaphoresis.
Musculoskeletal: No myalgia, stiffness, low back pain, or history of fracture.
Neurological: No dizziness, tremor, seizures, or loss of consciousness.
Psychiatric: No depression or insomnia.
Hematological: No bleeding tendency.
側頭動脈炎であるならば、visual disturbancejaw claudication, tongue claudicationなどを認めます。
Rheumatoid arthritisであるならばearly morning stiffnessなど古典的な所見として知られています。
SLEであるならばphotosensitive dermatitis, chest pain, loss of hair, ulceration in mouthなどがあげられます。
Polymyalgia rheumaticaであるならばshoulder pain, back painの質問が必要です。
Physical examination
146 cm, 43.2kg, BMI: 20.27
Consciousness: Alert
Vital signs
Body Temperature: 36.6ºC
Blood Pressure: 154/78mmHg
Heart Rate: 66 beats per minute.
Respiratory Rate: 20 times per minute
SpO2: 98% breathing ambient air
Mental Status: Alert
# Tachypnea
Head: Normocephalic and atraumatic.
Eyes: No conjunctival pallor and anicteric.
Ears: No discharge.
Nose: No discharge.
Throat: No erythema or exudate.
Sinuses: normal
Neck: Supple, no goiter or lymphadenopathy. No bruit.
Cardiovascular:Heart sounds: 1st and 2nd heart sounds were normal, no 3rd or 4th sounds and no murmur. Peripheral arteries: pulses normal and no laterality.
Respiratory: No central cyanosis. Trachea: Normal length and not deviated. Air entry: normal bilaterally. Normal vesicular breath sounds.
E; expansion;胸郭の広がりをみます。ちょうど横隔膜のラインに両手をできるだけ広げて親指同士を合わせます。そのとき患者さんには十分息をはいてもらった状態にしてもらいます。そこで大きく息をすってもらい、親指同士が10cm離れたら胸郭の広がりは良好と判断します。肺炎や拘束性肺疾患があるとこの距離は短くなります。次に前胸部に手をあてます。やはり大きく息をすってもらいます。通常ですと手は前方上方に押し上げられます。やはり拘束性肺疾患は可動性に限りがあるためあまり動きません。
P; percussion
A; auscultation
V; vocal resonance手でみるのを声音振盪(vocal fremitus)といいます。聴診では声音音響(vocal resonance)といいます。Consolidation;肺硬化があると音響は増強し胸水など水分があると音響は小さくなります。
Abdomen and Pelvis: Soft and non-distended. Bowel sounds were normal, no masses, and no hepatosplenomegaly.
Digital recital examination: No mass, or hemorrhoids.
Back: No costovertebral angle tenderness.
Extremities: No edema, or nail abnormalities.
Joints: Limited motion of her leftjoint; the shoulder flexes to 30˚, abducted to 30˚, and raised up at 30˚.
Lymphatics: No lymphadenopathy.
Dermatologic: Pigmentation on lower 1/3 of both lower legs
Peeling of skin about 4cm in length on right lower leg.
Cranial nerves;I-XII intact
Peripheral Nervous System
Tone: Normal. No hyper- or hypotonia.
Power(MMT): Deltoid muscle 4/5. All other muscle groups 5/5 bilaterally.
Reflexes: Normal throughout
Coordination: Normal; No dysdiadochokinesis, normal heel-to-shin test, and normal speech
Romberg sign: Negative.
Gait: No ataxia, but there was difficulty walking due to muscle weakness, arthralgia of ankle joints, and spinal canal stenosis.
Sensation: Nociception, temperature, and joint position sense: all intact.
Vibration: Right and left upper limbs were intact.
Pathological reflexes:
Hoffman -/-, Tromner -/-, Babinski -/-, Chaddock -/-.
Dr. Branch’s Pneumonic; ABCMST
A; HAV, Streptococcus group A, AIDS (HIV)
B; HBV, parvovirus B19,
C; HCV, Calp (gonorrhea, Consumption (Tuberculosis), Chronic meningococcemia, Chlamydia, Campylobacter (reactive arthritis)
M; Mumps
S; Syphilis, SBE, Salmonella/Shigella (plus E.coli)
T; Triple; Whipple disease, Three days measles; Mumps
Dr. Branch’s Pneumonic; RSPEVC
R; RA, RS3PE (remitting seronegative synovitis with pitting edema), Reactive arthritis,
S; SLE, Systemic sclerosis, Sjogren syndrome, (Adult) still’s disease
P; PMR, PM/DM, pseudo-goat/goat, paraneoplastic syndrome
E; eosinophilic fasciitis
U; ulcerative colitis
C; Crohn disease, cancer; lymphoma, leukemia
プレゼンター;ANA 160倍と高値でしたがリウマトイド因子やanti-CCP, jo-1, SS-A/B, P-ANCA等いずれも陰性でした。Blood cutureも陰性です。軽度の貧血を認めますが、正球性であることから炎症性変化と考えます。上部消化管内視鏡検査も特記すべき所見はありませんでした。