HPI: RS, a 38-year-old man, presents with a chief complaint of pain and stiffness of his hands, wrists, and knees that is most pronounced in the morning. He reports he hasn’t really felt right for the past year following his divorce. Initially, he thought the fatigue, malaise, anorexia, and weight loss were all related to the lifestyle adjustments he had to make. However, now that his life is in order and he is enjoying himself more he continues to be bothered by his symptoms. Moreover, the problem with his hands and knees is starting to impair his ability to work as a plumber.
RH states that he has been healthy without any history of prior medical problems. He has never been hospitalized, has no drug allergies, and is currently taking no medications. RH is active and enjoys the outdoors. However, he admits that it has been increasingly difficult to hike and fish due to the pain in his joints. He denies tobacco use but does report consuming one or two beers after work and on the weekends.
PE: T 37.0°C; BP 132/78 mm Hg; HR 88 beats/min; RR 18 breaths/min; SaO2 99%; Gen: Thin. NAD CVR: RRR, chest CTA bilaterally. Abdomen (Abd): Soft, nontender + BS (bowel sounds); Extremities (Ext.): + swelling, tenderness, and warmth over proximal interphalangeal (PIP) joints of both hands and knees.
Labs: WBC 7.5; Hct 42; Plt 360; ESR 98; ANA 1:250; rheumatoid factor 1:400.