A Patient Suffering From Pain and Malaise

Robert M. Centor, MD


March 14, 2006

Series Editor's Note

This series of cases offers an opportunity for you to work through the diagnostic process, determining what tests to order and which questions to ask. A discussion link is provided below to facilitate that process.

If you have an interesting acid-base or electrolyte case to share, we invite you to submit it for consideration. We are especially looking for problems involving Na, K, Ca, Mg, or Phosphate. If we accept your submission, I will work with you to achieve publication on this site as soon as feasible.

Case Presentation

JB is a 60-year-old man who comes in with complaints of pain. He currently has pain in his hands, shoulders, and hips. He first noticed the pain in his hands 2 months ago. He worked as a construction worker, and was no longer able to carry concrete blocks. Over the next month his pain spread from his hands to his hips and shoulders.

The patient has lost 13 pounds over 2 months. He had several NSAID trials (from other physicians) without relief. He complains of general malaise and great frustration.

The pain is worse in the morning, improving slightly during the day.

His hand pain is accompanied by swelling and stiffness.

His shoulder pain prevents him from touching his head.

His hip pain leads to a painful, slow gait.

On physical exam, he is entirely normal except for the musculoskeletal exam. His hand exam reveals symmetrical tender and spongy PIP and MCP joints of all fingers. His shoulders are tender. He is unable to resist motion of shoulders in any direction. His arm muscles are normal, with normal strength. The muscles are not tender. He is unable to resist hip motion, but again, his leg musculature is intact.

The Problem

What is the likely diagnosis?

What diagnostic tests would you order?

Would you treat him at this time?


Feel free to discuss this case with others. You can monitor or join in the Medscape discussion at http://www.medscape.com/px/discussions/29d4f79e.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.