Rheuma Case: 73-year-old Woman with Shoulder Pain

by Stephen Holt, MD, MS

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    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.

    About the Lecture

    The lecture Rheuma Case: 73-year-old Woman with Shoulder Pain by Stephen Holt, MD, MS is from the course General Approach to Arthritis and Joint Pain.

    Included Quiz Questions

    1. hip joint
    2. first metatarsophalangeal joint
    3. wrist joint
    4. distal interphalangeal joints
    5. metacarpophalangeal joints
    1. ...muscular weakness.
    2. increased ESR.
    3. ...giant cell temporal arteritis.
    4. ...increased CRP level.
    5. ...muscular pain and stiffness.

    Author of lecture Rheuma Case: 73-year-old Woman with Shoulder Pain

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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