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Morning Report

 16 yo female presenting with 10
days of diffuse joint pain, swelling of
her hands, feet, and face, other
“swollen joints” and intermittent
 Previously healthy
 10 days of bilateral PIP joints, wrists, elbows, shoulders, feet, ankles,
knees, hips, neck and back pain and possible swelling. Has now
been to the ED 4 times and treated with steroids and
 5 days ago began experiencing intermittent rash (started after
lying on some grass), large welts appearing first on her back and
side. Now affecting her palms, soles, scalp, and body. Has been
taking occasional doses of benadryl and loratadine with no
improvement. Very itchy. Some itchy eyes. No bleeding, bullae, or
 3 days ago got severe lip swelling but no respiratory symptoms. Got
 Yesterday got shortness of breath, felt like her heart was beating
quickly, and felt burning in her chest
 Has been seen in the ED 4 times in the past 5 days
 Evaluated by rheumatology today who recommended she be
admitted for further workup
 PMHx: “Healthy.” No PCP.
 Hospitalized once at age 7 for an episode of swollen feet and
rash that resolved after 3 days, no diagnosis
 PSHx: No prior surgeries
 Meds: No regular prescribed medications. During the past
week has received:
 Naproxen as needed, IV Benadryl, Famotidine,
Methylprednisone (125 mg x2), and Prednisone (40 mg x4 at
 Allergies: NKDA. No known food or environmental allergies
 FHx: Parent with history of rheumatoid arthritis.
 SHx: Recently spent 6 months living in central Mexico recieved
tattoos at the local parlor before she came back to the
 ROS: as above
 General: Alert and oriented, well nourished, no acute distress;

 Eye: PERRL, EOMI, normal conjunctiva; “normal” funduscopic exam

HENT: erythematous, swollen cheeks and nose (does not spare
nasolabial folds), NC, clear tympanic membranes, normal hearing,
moist oral mucosa, no scleral icterus
Neck: tender to palpation of spine; some tenderness along
paraspinal muscles as well; supple, no JVD, no lymphadenopathy

 Lungs: no wheezes, crackles, stridor; good air flow bilaterally, non-

labored respiration

 Heart: Normal rate, regular rhythm, no murmur or edema

 Abdomen: Soft, non-tender, non-distended, bowel sounds present,

no masses
- range of motion is diminished in some joints secondary to pain but
able to range fully when pressed
- knees, wrists, MCP, PIP, neck, hip, shoulder joints tender to palpation
- knee, wrist, PIP and MCP joints swollen bilaterally
- knee joints warm to touch bilaterally
- slight tenderness in muscles throughout, but pain more so at tendon
- joints without erythema
Flat, red macules present in between fingers, on palms, and on back;
no scale with rash; currently no raised lesions; Skin is warm, dry and well
- no signs of pitting on nails

Neurologic: Awake, alert, and oriented X3, CN II-XII normal

Psychiatric: Cooperative, appropriate mood and affect
Sodium Level: 141 mmol/L
Potassium Level: 3.6 mmol/L
Chloride Level: 107 mmol/L
CO2: 23 mmol/L
Anion Gap (Na Cl CO2): 11
WBC: 14.4 K/mcL Glucose Level: 161 mg/dL
RBC: 4.8 x10^6/mcL High
Hemoglobin: 14.5 g/dL BUN: 9 mg/dL
Hematocrit: 41.1 % Creatinine Level: 0.59 mg/dL
Estimated Creatinine
Neutrophil 90.8 %
Clearance: 119 mL/min
Lymphocyte 7.6 %
Calcium Level: 10.1 mg/dL
Monocyte 1.3 % Protein Total: 8.6 g/dL High
Eosinophil 0 % Albumin Level: 4.8 g/dL
Basophil 0 % Bilirubin Total: 0.7 mg/dL
Alk Phos: 74 unit/L
AST: 32 unit/L
ALT: 59 unit/L
Lactic Acid, Plasma (Venous): SSA (Ro) Ab: Negative: <0.2
2.4 mmol/L
SSB (La) Ab: Negative: <0.2
HCG, Beta Quantitative: <2
Scl-70 Ab: Positive: 2.1 (ELISA)
ANA Screen: Positive
(ELISA)/Negative (IFA)
Jo-1 Ab: Negative: <0.2

dsDNA Ab: Negative: <0.2 Centromere Ab: Negative:

RNP Ab: Negative: <0.2
Ribosomal P Ab: Negative: <0.2

Sm Ab: Negative: <0.2 Chromatin Ab: Negative: <0.2

Rheumatoid Factor: <15


GC/CT negative
HLA-B27 normal
RPR negative
HepBSAB, HepBcAB, HepBsAg, HepCAB all neg
aldolase, IgM, IgA, IgE, IgG, vWF, Cryoglobulin, EHEC
toxin, Stool culture, urine culture all negative/normal

 Email with any

questions or discuss over lunch