Rheumatoid Arthritis and Erythrocyte Sedimentation Rate...

Differential Diagnosis Paper 2 Taylor Clark
NGR 6002C University of South Florida

I would begin the physical assessment with an evaluation of the patient’s skin. Based on the patient’s chief complaint osteoarthritis (OA) and rheumatoid arthritis (RA) are possible diagnoses. Both diseases can lead to joint and bone destruction, nodules, and lesions. I would evaluate the skin for temperature, symmetry, and color. Warmth, redness, and joint deformities are indicative of both diseases.
Next, I would examine the respiratory system. RA can involve the lungs and progress to pleural effusions, interstitial fibrosis, nodules, and pneumonia (MEDSCAPE). A small study found a high prevalence of pulmonary inflammation and fibrosis in patients with newly diagnosed RA. I would begin my assessment of the respiratory system by inspecting the patient’s chest, posterior thorax, and looking at the patient’s breathing patterns. I would then check for capillary refill. Next, I would palpate the anterior and posterior thorax wall for enlargements, masses or tenderness. While palpating the posterior thorax I would check for tactile fremitus and then percuss the posterior and lateral thorax for resonance to determine if there is any consolidation. Lastly, I would auscultate the anterior, posterior and lateral thorax to determine if there are any decreased breath sounds.
Thirdly, I would examine the cardiovascular system. RA can lead to cardiovascular complications such as pericarditis, cardiomyopathy, arrhythmia, and congestive heart failure (Voskuyl 2006). I would begin with an inspection of the pericardium, jugular vein, upper extremities and lower extremities for edema. Next, I would palpate the carotid, apical, and radial pulses. To conclude the cardiovascular exam, I would auscultate the heart sounds with the bell and diaphragm for any arrhythmias or murmurs.
Lastly, I would examine the musculoskeletal system. Fibromyalgia, OA and RA cause joint stiffness, swelling, and decreased range of motion. I would begin by inspecting the joints for symmetry, deformities, and alignment. Next, I would palpate the bones for tenderness, heat, edema, and crepitus. Crepitus is a common finding in osteoarthritis (Kraus et al 2009). Based on the patient’s chief complaint I would evaluate range of motion and strength testing in both hands and wrists. I would check for flexion and extension of the wrists and fingers. Following that I would evaluate radial and ulnar deviation, abduction and adduction of the fingers, and strength of the hands by asking the patient to squeeze my hands.
Three differential diagnoses that can be drawn from the chief complaint: OA, RA, and fibromyalgia. RA is a chronic systemic inflammatory disease. An autoimmune reaction occurs by an external trigger such as trauma or smoking. RA begins with a fever, malaise, fatigue, and arthralgia and leads to joint inflammation and pain. Physical examination findings of rheumatoid arthritis include swelling, deformity, rheumatoid nodules, pain on motion, and joint tenderness. There are no pathognomonic tests but a combination of labs and results lead to the diagnosis of RA (Aletaha 2010). The erythrocyte sedimentation rate, C reactive protein level, complete blood count, rheumatoid factor assay, and the antinuclear antibody assay are useful laboratory studies (Aletaha 2010). To further confirm diagnosis radiographic studies should be performed which would show cartilage loss (Aletaha 2010). A CT or MRI can be performed to show surrounding joint soft tissue. An arthroscopy can be done to evaluate synovial fluid. The patient in the case study has signs and symptoms consistent with RA including stiffness, joint pain, and fatigue.
OA is a degenerative disorder that occurs from the breakdown of hyaline cartilage in the synovial joints (Kraus et al 2009). Signs and symptoms of OA include joint pain that is exacerbated by use, joint stiffness more often in the morning, reduced

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