THE REPORT

The demographic features of the man comprise 69 years and male. There is no medical history as the
person was healthy until the appearance of the current disease.

The main complaint (MC) include non-specific joint pain where the pain occurs all throughout the body
without any prior reasons. Signs include joint swelling, which is an inflammatory manifestation, without
erosion (no bone cell degradation, therefore, no loss of bone). Pain in elbow, wrist, hand and knees
were the symptoms. The patient has been treated with analgesics such as acetaminophen and others to
relieve the pain.

The Past Medical History (PMH) can have to categories; Seven months ago, the person experienced
stiffness in both hands in the morning so that he could not use the wrist and ankles for more than one
hour, he could not stand at work and home due to the ankle pain. Therefore, he was treated with
800mg of Ibuprofen three times daily. Ibuprofen is a non-steroidal anti-inflammatory drug that treats
pain and inflammation. Three months ago, the pain had started to develop in both shoulders.
Furthermore, he experienced extreme tiredness and no energy to do work. He became short-tempered.
The Ibuprofen treatment was ineffective.

On admission at the emergency, he suffered from weakness and hematemesis. His hematocrit was low
(21%), whereas the normal hematocrit of a male has to be 41% to 50%. Endoscopy was done to obtain
images of the internal body. This imaging technique revealed a large bleeding ulcer and fresh blood in
the stomach. Echocardiography visualizes the internal structure of the heart. This investigation showed
that the right ventricle was compressed and a pericardial structure was present in the subcostal view.

There is a wide spectrum of suspecting diseases. The usage of steroid and non-steroidal anti-
inflammatory drugs helps to include and deduce that it is an inflammatory disease, where analgesics and
Ibuprofen are pain killers (pain is a cardinal sign of inflammation).The clinician had suggested and the
patient had used immunomodulators which are a group of drugs to modify the immune system. Hence,
we can include an immune system related disorder. Joint pain, bone swelling without erosion, lack of
energy to do work, inability to stand and work, stiffness and extreme tiredness contributed to the
assumption and inclusion of a disease related to the skeletal system. Fatigue is observed when there is
less ATP due limited aerobic respiration in muscles. The hematocrit (HCT) is only 21%, whereas a healthy
male should have it between 41% and 50%. There was bleeding and fresh blood in the stomach along
with hematemesis upon admission to the hospital. Therefore, a blood disorder can be included. A
disease in the circulatory or cardiovascular system can be included as the 2-dimensional echocardiogram
which showed a compressed ventricle and a pericardial structure in the subcostal view. The endoscopy
test showed a large bleeding ulcer with fresh blood in the stomach and intestines. Moreover,
hematemesis (vomiting of blood) leads to the inclusion of a Gastro-Intestinal (GI) tract related disease.
Other investigations led to the interpretation of many diseases. The White Blood Cell (WBC) count of the
patient was found to be 13 X 109 per liter of blood. However, the normal WBC count of a male has to be
between 4.5 and 11.0 X 109 per liter of blood. Therefore, the number of WBCs are higher, as a result, an
infection or inflammation can be included. The Hemoglobin (Hb) level of the patient is 14g/dL which is
within the normal range (13.8-17.2 g/dL). Therefore, there are no abnormal HB related conditions; Hb
related diseases such as anemia, bone marrow or red blood cell related cancer can be excluded. The
Erythrocyte Sedimentation Rate (ESR) of the patient is 19 mm/hr. This value is normal as it is within the
standard range (0.0-22 mm/hr). The ESR test is important to know if the patient has a condition that
causes inflammation or bowel disease. Therefore, any infection, temporal arthritis, anemia or vascular
related disease can be excluded as the ESR is not high. Further, congestive heart disease can be excluded
as the ESR is not low. The C-Reactive Protein (CRP) level of this patient is 36 mg/l which is greatly above
the normal range (0.3 – 1.0 mg/l). As a result, a heart disease, particularly the inflammation of the heart
can be included.

The two main disease categories that can be excluded are digestive disorders and blood related
disorders. The GI tract disorder was considered only due to the endoscopy result, but symptoms or signs
related to any such disorder was not present in the MC and the PMH. The showcase of ulcer, bleeding,
fresh blood in the stomach and intestines and hematemesis were the result of adverse effects due to
Ibuprofen consumption. Therefore, we can exclude GI tract disorder. Bone marrow related,
hematopoiesis related and blood related disorders can be excluded. It is the bleeding in the stomach
and hematemesis (adverse effects of Ibuprofen) that caused the HCT to decrease, but still the Hb count
and the ESR was normal. If it was a blood related disorder, the Hb count and the ESR level has to be
abnormal.

An inflammatory disease can be included as the WBC count is high and the CRP level is high. These two
manifestations were present in the MC and the PMH. The person was treated with analgesics against
inflammation. This is an inflammatory condition that affects the skeletal muscles as it caused joint pain.
This is also an immune system related disorder because immunomodulators were prescribed. Therefore,
we can assume that this is Rheumatoid arthritis which is an autoimmune disease that affects both, the
muscles and bones.

The diseases that can be included in the differential diagnosis are Rheumatoid arthritis, peridarditis,
endocarditis, myocarditis and cardiomyopathy.

In the final diagnosis, It can be confirmed that the disease is Rheumatoid arthritis with pericarditis. The
CRP elevation showed that there is an inflammatory condition in the heart. The 2D-echocardiogram
showed that there is a pericardial structure. As a result, it is confirmed that the person suffers from
pericarditis where the pericardium is inflamed.

To confirm that it is rheumatoid arthritis, a blood test should be done to check for rheumatoid factor
and anti-cyclic citrullinated peptide (anti-CCP) antibodies along with imaging techniques like X-rays, MRI
and ultrasound. To confirm that it is pericarditis, diagnostic procedures such as chest X-ray,
electrocardiogram (ECG), Cardiac Computerized Tomography (CT) scan and Cardiac Magnetic Resonance
Imaging (MRI) techniques.

To treat rheumatoid arthritis, conventional and Targeted synthetic DMARDS along with monoclonal
antibodies can be prescribed. Moreover, a suitable surgery such as synovectomy, tendon repair, joint
fusion or total joint replacement can be done. To treat pericarditis, medication such as pain relievers,
Colchicine and corticosteroids can be prescribed. As surgeries, pericardiocentesis and pericardiectomy
can be suggested.