00:00
Alright. So let's move on to our next case. So this is a 73-year-old woman who presents to
your office with shoulder pain. Her past medical history is notable for hypertension and
hypothyroidism. Initial vitals; temperature of 37.7, heart rate of 76, and a blood pressure of
134/65. Now remember those 4 variables we talked about before. That's the kind of questions
that we're going to want to ask to get more information about this case. So, what's the time course?
What sounds like she has had these bilateral shoulder pain symptoms that have been slowly
progressive over the past 2 or 3 weeks? Next up, what's the pattern of joint involvement? Or if
he got bilateral shoulders so some degree of symmetric findings, but also this involvement of
the right hip. So there's both symmetric and asymmetric features and we'd call this also
oligoarticular. We've got 3 joints involved. Thirdly, evidence of joint inflammation. A little bit
tricky to tell based on the information we have thus far, we'll need to get a physical exam. And
then fourthly is their systemic involvement. Ahh, she is reporting some general malaise,
intermittent low grade fevers over the past few weeks. So yeah, I'd say she has systemic
involvement. So just based on that information, we should be able to hone in on our differential
diagnosis and here's our exam. Cardiopulmonary is a benign exam. On musculoskeletal exam, we
have pain with active and passive range of motion of both shoulders. So that may lead us to
think about evidence of joint inflammation. Strength is full throughout though pain limited. No
bony deformities and her skin exam is essentially normal. So, what is the most likely diagnosis in
this case? Septic arthritis shown here, unlikely. Septic arthritis tends to be monoarticular. It
would be pretty unusual to get 3 joints involved. Shown here in this slide is a picture of some
gram positive cocci in clusters pretty typical of <i>Staph aureus</i>. Next up, polymyalgia rheumatica.
02:02
PMR, you're going to need some evidence of inflammation confirmed with an erythrocyte sedimentation
rate or C-reactive protein, but this is a pretty typical pattern. And bilateral shoulders,
involvement of the hips in elderly patient, we're going to have to keep this one on our list.
02:18
Osteoarthritis as we discussed before, certainly this is a common joint that's involved the hip;
however, we wouldn't expect the subacute presentation over just 2 or 3 weeks and we certainly
shouldn't have systemic symptoms with osteoarthritis of any kind. And lastly, adhesive capsulitis
also known as frozen shoulder. That's a relatively common condition, can happen in the elderly,
folks with diabetes and it tends to involve a progressive stricture of the glenohumeral capsule
that leads to decreased range of motion over time, but it's unlikely to be bilateral and again
shouldn't have systemic symptoms. So just based on a limited information that we have, it's kind of
look and like polymyalgia rheumatica. So let's talk about that for a moment. PMR is a rheumatologic
condition common in the elderly as we've discussed and it's not really a muscle problem even
though the name polymyalgia would suggest that. Instead, it's an association of several
peri-articular problems. Biceps tendinopathy, subacromial bursitis or inflammation of the bursa
that lies between the acromion and the humeral head. And then glenohumeral synovitis, that is
the capsule around the glenohumeral joint is inflamed. There are no problems with the muscle
and there are no problems with the joint itself, but it oftentimes, as I said can present with
bilateral hip and shoulder problems as we're seeing in our case. To confirm the diagnosis though,
we would really need to see elevations in the ESR and the CRP that would support our final
diagnosis.