Presenting Complaints

• 39-year-old female patient presenting with progressive joint swelling and pain for the past 3 months.

History of Presenting Complaint

• The patient reports that the swelling and pain started in her hands and wrists, and has gradually spread to her knees and ankles over the past 3 months.
• The swelling is accompanied by stiffness, especially in the mornings, which can last for several hours.
• She denies any recent injuries or trauma to the affected joints.
• She reports feeling fatigued and experiencing occasional low-grade fevers.
• The symptoms have been interfering with her daily activities and ability to perform her job.

Significant Positives & Negatives For Differentials

Rheumatoid Arthritis

Positives:

• Progressive, symmetric joint swelling and stiffness
• Morning stiffness lasting several hours
• Positive family history of rheumatoid arthritis
• Fatigue and occasional low-grade fevers

Negatives:

• Lack of rashes or eye inflammation
• Absence of sudden, severe joint pain (as seen in gout)
• No recent injuries or trauma to the affected joints

Reactive Arthritis

Positives:

• Recent viral upper respiratory infection
• Symmetric joint involvement

Negatives:

• Lack of other characteristic features like conjunctivitis, urethritis, or skin lesions
• Symptoms persisting for 3 months rather than resolving within a few weeks

Osteoarthritis

Positives:

• Joint swelling and pain

Negatives:

• Symmetric involvement of multiple joints, rather than the typical asymmetric, single joint presentation of osteoarthritis
• Onset at a relatively young age (39 years old)
• Presence of morning stiffness lasting several hours

Psoriatic Arthritis

Positives:

• Symmetric joint involvement

Negatives:

• Lack of skin manifestations of psoriasis
• No history of nail changes or dactylitis

Gout

Positives:

• Joint swelling and pain

Negatives:

• Absence of sudden, severe joint pain (typical of gout flares)
• Lack of involvement of the first metatarsophalangeal joint (a common site of gout)

Past Medical History

• The patient has no significant past medical history.
• She reports a viral upper respiratory infection about 2 months ago, which resolved within a week.

Drug/Medication History

• The patient is not taking any regular medications.
• She has tried over-the-counter anti-inflammatory medications, which provided mild relief but did not resolve the symptoms.

Social History

• The patient is married and works as an office administrator.
• She denies any tobacco, alcohol, or recreational drug use.

Family History

• The patient's mother was diagnosed with rheumatoid arthritis at age 55.

Systems Review

• Review of systems is positive for joint swelling, pain, and stiffness, as well as fatigue and occasional low-grade fevers.
• Negative for rashes, eye inflammation, chest pain, shortness of breath, or gastrointestinal symptoms.

Ideas, Concerns & Expectations

• The patient is concerned that the joint swelling and pain may be a sign of a more serious underlying condition and is hoping for a diagnosis and effective treatment plan.

Case Presentation

Based on the patient's history of progressive, symmetric joint swelling and stiffness, morning stiffness, fatigue, and positive family history, the most likely diagnosis is rheumatoid arthritis. The differential diagnosis could include reactive arthritis, osteoarthritis, psoriatic arthritis, and gout, but the clinical presentation is most consistent with rheumatoid arthritis. Further diagnostic tests, such as rheumatoid factor and anti-citrullinated protein antibody (ACPA) testing, as well as imaging studies, would be helpful to confirm the diagnosis and guide appropriate treatment.