FCM Sample Write-Up #6
Term 2, Spring Quarter
Sample B

ID/CC:

M.O. is a 41-year-old woman with a 10-pack year history of tobacco use, admitted with severe swelling and polyarthralgia of bilateral digits, right worse than left.

HPI:

M.O reports 2 months of painful, swollen digits on her bilateral hands and feet, worse on the right that began suddenly when she woke up one morning. The pain started as 9/10 severity and was described as “feeling like frostbite” with numbness, itchiness, throbbing, and tingling that is significantly worse at night. The pain is aggravated by palpation, but unchanged by movement. The patient denies any weakness or limited range of motion but notes that it progressively spread to her knees and ankles until she was unable to get out of bed due to pain 1 week after initial onset. She endorses fatigue.

Before her stay at UWMC, M.O. was first seen at the ER @ St. Joe’s in Tacoma three times for her symptoms but all tests and imaging done there were normal except for an elevated WBC. Each time, patient was discharged with a diuretic and hydrocodone/acetaminophen which improved her pain but had no effect on her swelling. Three weeks ago, the patient came to UW and was referred to a rheumatologist who started her on a 14-day course of prednisone that improved both her pain and swelling. However, on her follow-up visit with rheumatology after finishing the steroid course, she was directed to immediately go to the UW ED due to the increased discoloration and coolness of her 2nd and 3rd right hand digits. Notably, patient has a 29-year smoking history of 1/3 pack-per-day but reports no tobacco use in the past one month.

During her present hospital stay, M.O. reports improvement in pain control (currently 6/10 severity on hydromorphone and gabapentin) but notes that the ischemia and sensation in her fingertips have continued to deteriorate. Currently, the initial throbbing, tingling pain has spread to the distal portions of 1st and 4th digit on the right hand, the 2nd digit on the left hand, and the 1st big toe on her right foot. She reports a complete lack of sensation in her 2nd right hand digit and decreased sensation in all other affected digits. The patient has also developed additional symptoms since being admitted including increased appetite, urgency to urinate, irregular menstruation, and heat intolerance. She also notes a non-itchy, dry, bumpy rash on her left upper lip and beneath her breasts bilaterally. One week into her stay, she acquired a paralyzed left vocal cord with associated hoarseness and dyspnea from being unable to take a full breath, no history of intubation. Patient denies current fever, chills, weakness, chest pain or palpitations and is able to independently get out of bed, ambulate, and use the bathroom.

A full workup of labs and imaging studies was performed with multiple consults from ENT, rheumatology, surgery, endocrinology, medicine, and surgery. Imaging showed multiple blood clots in bilateral upper and lower extremities as well as a “hole in the heart”.

PMH:

Childhood Illnesses: No Significant History

Adult Medical Illnesses:

• Chronic Migraines (about x4/month)

Past Surgical History:

• s/p Abdominoplasty (2016)
• s/p Appendectomy (1988)

Medications (in hospital):

1. hydromorphone
2. gabapentin 300 mg q8hr

Drug Allergies: No known drug allergies

Health-Related Behaviors:

• Tobacco: per HPI
• EtOH: Quit x3 years ago; previously had a “couple drinks a week”
• Recreational Drugs: Denies marijuana use; Denies any other recreational or IV drug use.
• Diet: Endorses healthy diet with 4-5 small meals per day; currently snacking more frequently due to increased appetite; reports 30 pounds of unintentional weight gain in the past month
• Exercise: Reports extremely active work life (barista) and taking walks 2-3x/week before current illness
• Sexual History: did not obtain

Preventative Health: Was not previously followed by PCP; will be seeing Dr. Maria Hernandez (family practice) after discharge

Family History:
Father: Deceased at age 42 (Myocardial Infarction)
Mother: Currently alive, lives near patient in Tukwila
No known significant history of cancer or autoimmune disease

Social History:

Patient was born and grew up in Tukwila, WA. She was assigned female @ birth and is a cisgender woman. She has a son (age 25) and daughter (age 19) and currently lives in a house with her husband and mother. Her daughter is married and also lives locally. She currently works as a barista, but has been on an extended leave of absence since April 2019. Besides her job, she states that she is constantly moving around and often babysits and cleans houses for her friends and neighbors.

She reports some financial stress over paying for her current hospital stay but is more focused on “taking it day by day”. Following an occupational injury in 2016, her husband has been on permanent disability and has been able to spend time at home with her. M.O. identifies as Catholic and finds significant support and strength in practicing her faith. She has been seeing the hospital’s chaplain regularly during her stay. She also reports relying on her husband, mother, and daughter for social and emotional support and believes that her relationships with them as well as her faith help her remain positive and hopeful.

ROS:

Constitutional: Endorses positive weight change (30 lbs in past 1 month), increased appetite, weakness, and night sweats. Denies fever or chills.|
Head, Ears, Nose, Mouth, and Throat: Reports headache and hoarseness. Denies changes in taste, vision or hearing, tinnitus, epistaxis, nasal discharge, vertigo, eye pain, or ear pain.
Breasts/Axilla: Endorses left axillary mass that is tender to the touch; denies discharge Pulmonary: Endorses dry cough and dyspnea. Denies wheezing, hemoptysis, or sputum Cardiovascular: Endorses edema. Denies orthopnea, claudication, chest pain, or heart palpitations.
Gastrointestinal: Endorses increased appetite. Denies abdominal pain, indigestion, jaundice, nausea, stool changes, diarrhea, melena, vomiting, or constipation
Genitourinary: Endorses urgency with x2 episodes of incontinence. Denies dysuria, hematuria, or increased urinary frequency
Musculoskeletal: per HPI; Denies trauma, large joint pain
Integumentary: Endorses hair thinning, nail changes, pruritus in heels and hands, and rash on right upper lip and below breasts; see HPI
Neurological: Reports numbness in affected digits – per HPI; Denies syncope, speech issues, or problems with gait/coordination.
Psychiatric: Endorses change in sleep pattern. Denies anxiety, depression or memory loss.
Menses/Pregnancy: GPA: 2/0/1; endorses irregularity (menstruation x2 weeks early)
Endocrine: Endorses polydipsia and heat intolerance

Physical Exam

Vital Signs: BP: 118/72; Pulse: 96; Respiratory Rate: 16
General: M.O responds to questions, is able to sit upright in bed, appears tired, but in no acute distress.
Skin: Nails are cracked and dome-shaped on bilateral hands and feet; No jaundice; Macular redness with scattered papules on right upper lip and beneath breast tissue bilaterally; Right hand: 2nd digit is dusky, cool to the touch; 3rd and 4th digits are less dusky; 2nd, 3rd, and 4th digits are all tender to palpation, show multiple hemorrhages in nail beds, and have ulcerations on distal tips with eschar; Left hand: 2nd digit is dusky, cool to touch; Right foot: lateral malleolus is slightly swollen, nonpitting; interrupted sutures x 2 noted on interior dorsal surface with blanching redness surrounding incision area; Skin is otherwise normal, warm, and dry
HEENT:

• Scalp: Normocephalic. Face, scalp and skull without lesions or tenderness. Normal hair pattern
• Eyes: mild scleral icterus bilaterally. Vision not assessed. Conjunctivae without injection. Lids without lesions.
• Ears: No tenderness upon palpation. No erythema.
• Nose: External nose without lesions or asymmetry. No frontal or maxillary sinus tenderness
• Mouth/Throat: Normal dentition. Gums without erythema or bleeding. Tonsils not visualized
• Neck/Thyroid: Tender axillary node in left axilla. No palpable cervical, anterior, or subclavian lymphadenopathy.

Chest: Breathing symmetrical without use of accessory muscles, No tenderness on percussion of spine or CVAs, Lung fields resonant to percussion bilaterally. Symmetric chest expansion, Normal vesicular breath sounds, No wheezing, stridor, crackles, or rales, Normal spinous processes.
Cardiac: JVP @ 8 cm, regular rate and rhythm, Apical impulse was not palpated, Normal S1/S2 sounds, No murmurs, rubs, or gallops.
Abdomen: Abdomen is distended and but non-tender to palpation and percussion, Active bowel sounds present, No palpable masses, liver span 10 cm @ MCL, no palpable spleen tip or liver edge.
Ext: 1+ edema in bilateral ankles
Neurologic:

• Mental Status: A&O x3. Speech fluent, articulate, but with some drowsiness
• Cranial Nerves: Cranial nerves II-XII intact
• Motor: Strength is 5/5 bilaterally in upper and lower extremities.
• Reflexes: 2+ BR, biceps, patellars bilaterally, 2+ triceps and Achilles, toes downgoing bilaterally.
• Sensation: Absent sensation in Right hand 2nd digit. Decreased sensation in distal parts of the 3rd and 4th digit of right hand, 2nd digit of left hand, and right toes. Sensation is otherwise intact to light touch in bilateral upper and lower extremities.
• Cerebellum: Normal Heel-to-Shin. Normal Finger-to-nose. Gait not assessed

Summary:

M.O. is a 41-year-old woman with a 29-year history of tobacco use who presents with severe pain and ischemia, and swelling in her bilateral distal digits of the hands and feet, worsen on her right side. Her physical exam is remarkable for duskiness, small hemorrhages, tenderness, and decreased sensation in affected distal digits. Other pertinent exam findings include distended abdomen, palpable tender left axillary lymph node, and intact 5/5 strength in all extremities.

Assessment:

The most likely etiology of M.O’s severe distal digit pain and joint swelling is thromboangiitis obliterans, otherwise known as Buerger disease. Patients with Buerger disease experience intense pain and possible paresthesias in the hand and feet even during rest, quickly progressing to skin ulcers and digital gangrene. The patient’s symptoms, age of presentation, and physical exam findings, as well as her positive history of tobacco use and negative history of vascular or cardiac disease make this diagnosis more likely. However, because thromboangiitis obliterans is classically seen in adult male, patient’s XX sex makes this diagnosis less likely, although still probable. Other underlying conditions considered were Raynaud phenomenon, psoriatic arthropathy, rheumatoid arthritis, vasculitis, and sarcoidosis. More epidemiologically common diseases including peripheral vascular disease with associated peripheral neuropathy should also be worked up to determine if patient’s negative history of cardiovascular disease is accurate.

A small-vessel primary or secondary vasculitis and Raynaud phenomenon were also considered due to its similar vascular pathology involving intermittent arteriolar vasospasms. Diagnosing primary Raynaud phenomenon is less likely because the patient presented after age 30, and did not show classic symptoms of symmetric mild digit pain that excludes the thumbs. However, Raynaud’s can also sometimes be secondary to Buerger disease, and is often more asymmetric with significant pain and development of ulcers and necrosis, thus not precluding its diagnosis entirely. Small-vessel vasculitis secondary to SLE or other immunogenic cause such as polyarteritis nodosa and Leukocytoclastic vasculitis were also considered due to patient’s sex, fatigue, and small hemorrhages around and beneath her distal nailbeds. Immune-mediated vasculitis has also been associated with unilateral vocal cord paralysis. However, both PAN and LCV involve immune complex depositions, autoantibodies, and inflammatory mediators and are often associated with infection or drug use. Patient also did not report any subcutaneous nodules, palpable purpura and her hemorrhages are not consistent with a classic presentation of vasculitis.

Initial evaluation of patient presenting with joint paint should first focus on determining whether pain is inflammatory or non-inflammatory in nature. Both were considered but osteoarthritis was less likely due to acute and severe onset and lack of symptoms in larger or weight-bearing joints. Inflammatory and immune-mediated diseases including psoriatic Arthropathy and RA were considered. Patient has no history of psoriasis or any skin conditions previous to current presentation. Her physical exam of tender painful digits and swelling at entheses are consistent with immune-mediated arthritis but there was no obvious dactylitis or nodule enlargement. Rheumatoid arthritis is more likely due to its age of onset and because it is 3x more common in women than in men. Patient notes that her pain is worse during immobility, consistent with RA, but also does not improve with NSAID or activity. Further, throbbing and frost-bite like pain with swelling and eventual numbness that is worse at night is not suggestive of an arthritic process. Physical exam was also negative for rheumatoid nodules or any other systemic symptoms outside of her hands and feet.

Sarcoidosis is a serious but less likely diagnosis due to the fact that approximately 25% of patients’ have cutaneous involvement and skin-limited disease is not uncommon. However, papules and plaques in sarcoidosis tend to be located on the face, neck, and upper trunk which is not consistent with her distal extremity symptoms. Her lack of systemic symptoms, notably lung involvement, also decreases suspicion but punch biopsy and chest x-ray should be done to rule out the diagnosis definitively.

Plan:

• A full cardiovascular workup should be completed to definitively rule out peripheral arterial disease and other cardiovascular etiologies of disease.
• Serologies for ANA, ANCA, Rheumatoid factor, and other antibodies should be ordered to confirm or rule out a vasculitis process. CBC, ESR, CRP, and urinalysis should also be considered to detect any systemic involvement.
• For workup of Buerger disease, digital subtraction angiography and continuous-wave Doppler ultrasound should exhibit characteristic recanalized thrombosed vessels and corkscrew collaterals around areas of segmental occlusion.
• Although patient is requesting amputation at this time, the current plan is to wait for auto- amputation in order to better understand the extent of occlusion in joints.
• Most importantly, a complete tobacco cessation program should be discussed with the patient as well as routine follow-up, due to the difficult nature of quitting. In patients in which disease continues to progress despite tobacco cessation, current therapeutic options remain limited. Revascularization is rarely indicated and usually unsuccessful because of the diffuse and distal distribution.
• Although there is no current standardized treatment, Prostacyclin derivatives (PGI2) have been shown to be effective over placebo and may be considered later on in the case of refractory or worsening symptoms.
• The patient’s remaining hospital course will be focused on symptom management, continued monitoring of ischemic progress, and coordination with an outpatient near her home in Tukwila to continue providing regular pain medication. The patient’s objective is to return to live at home with her husband and continue working, so OT and vocational therapy referral should be discussed as well to meet her goals.