Case 1: Physical Exam

Case 1 Index

Physical exam

Vital Signs: BP 135/84, HR 110, T 37.7 (99.9F), RR 10, SpO2 = 98%, BMI 27.6

General Appearance: appears uncomfortable but no acute distress
HEENT: PERRL, clear conjunctiva, anicteric sclera, no mouth ulcers
Lymph: No lymphadenopathy
Cardiovascular: no JVD, normal rate, regular rhythm, no murmurs, no gallops, no rub, no pulses
Pulmonary: clear to auscultation, good air exchange
Abdominal: bowel sounds present, soft, non-tender, non-distended, no hepatomegaly, no splenomegaly
Extremities: warm and well perfused extremities, no pitting edema
Neurologic: alert and oriented x4, 5/5 strength in upper and lower extremities, intact sensation to light touch throughout
Psychiatric: Calm, pleasant, cooperative
Skin: redness, warmth, and exquisite tenderness to palpation over joints marked; no nodules, rashes, skin deposits, periungal hemorrhages, or palmar/solar hemorrhagic lesions; nails without pitting

Detailed MSK exam: as illustrated by RheumSimBot© below:

RheumSimBot Case1

What’s at the top of your differential diagnosis in this patient? Choose 3 before moving on!
Polyarticular gout
Septic arthritis
Reactive arthritis
Rheumatoid arthritis
Viral polyarthritis
Calcium Pyrophosphate Dihydrate Deposition Disease
Deep Venous Thrombosis

Click here to move on!

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