3. The Check-up
‘I came for a check-up.’ A thin, good-looking woman said as soon as I welcomed her into my office. Paula Rogers was 60-years-old according to her records, but her hair was remarkably beautiful, almond and long, which made her look younger.
I was in outpatient service in the general health clinic. Mrs. Rogers was my last patient and although I confess the ‘check-up’ chief complaint is not one of my favorites, I learned an important lesson from Paula.
‘I see, Mrs. Rodgers.’ I smiled thinking of my standard follow-up questions when I decided to ask a question that would change the rest of that consultation. ‘And why is that? Are you feeling well or is there something bothering you?’
‘Well.’ She started scratching her head. ‘I have been having some problems at work you know, I think I’m a little weak. So I just want to make sure everything is ok.’
‘Oh, and when did that start?’
‘A month ago. I remember it was 2 days after my son’s wedding. Since then, it’s like I don’t have the same strength as I used to, it’s becoming harder to do things at work. It’s like my arms and legs are locked in.’ She pointed at her shoulders and thighs. “Even to get dressed it’s upsetting. My husband says it is probably empty nest syndrome after Ethan’s wedding, but I don’t think so.’
‘What do you work with?’
‘I am a hairdresser.’ I smiled at myself.
She then told me how she had never felt like that before and I began frowning. Something was definitely going on with her. How did this woman change overnight? I started a series of questions looking for other clues.
‘Do you also ache or just feel weak and stiff?’
‘No, they hurt also, my muscles.’ She gripped her shoulders.
‘Are you having any fevers?’
‘Hum… I am not sure actually. Sometimes I suddenly get all sweaty. And sometimes I feel cold. But true fever I am not sure.’
‘Okay.’ I answered thinking about what to make of that. ‘Weight changes?’
‘I lost maybe 5 pounds. Which I wouldn’t say I’m upset about.’ She laughed and I smiled back, even though I was getting a bit more worried with each answer.
‘Anything else at all? Fatigue, other pains, swelling, headache…’
‘Headache! Yes, I am also having an annoying headache.’
‘Since when?’
‘Since two days after my son’s wedding! I told you.’ She said it like it was obvious.
Something clicked right then inside me. I asked her more about the headache and she showed me how it hurt on her frontal and right temporal area of the head. With a few more questions I found that chewing could be painful as well.
‘And that weakness you were telling me about. When it gets to the end of the day, are you feeling better or worse than early in the day?’
‘You know what,’ She said like she was thinking about it for the first time. ‘I feel better.’
By then, I already knew what Paula had. I couldn’t believe how textbook-like her presentation was. Moving on to her past medical history and other aspects of her health, there was nothing else other than a well-controlled hypertension. So I went to her physical. Her muscle strength was normal and symmetric, but when I asked her to lift her arms above her head, she couldn’t abduct them past 90 degrees. The rest was pretty much normal except for the cherry on her physical: her temporal arteries were prominent on palpation.
I asked Mrs. Rogers to wait for me while I excused myself to discuss her case with Dr. Rivers, who was the attending in the clinic that afternoon. I found him in a computer with that big briefcase he carried around beside him. He was reading about some new hospital policy I probably should be reading as well.
‘Hi, Dr. Rivers.’ I said and he turned to me, set his glasses up on his nose, and smiled.
‘Hi, Dr. Diaz. How can I help you?’
‘Could I discuss a case with you?’
‘Please.’ He said and pointed to an empty chair in front of him.
I sat and started.
‘I just saw Mrs. Rogers. She is a 60-year-old woman with a chief complaint of proximal muscle weakness and stiffness for a month. She was in her usual health when her symptoms started overnight. Since then she has been having a hard time dressing herself and working as a hairdresser. Her upper limbs seem to be more affected than her lower limbs. She feels worse in the morning and better by the end of the day.’ He nodded and I continued.
‘She has also been having a frontotemporal headache in the same time frame and jaw claudication. She has had some moments of excessive sweat, some of them at night time, and is unsure if she has had fever at some point. She has unintentionally lost 5 pounds.’
I quickly went through the rest of her H and P and went to my impression.
‘So I believe she has a case of Polymyalgia Rheumatica associated with giant cell temporal arteritis. I would like to order some initial tests, including ESR, c-reactive protein, CK, transaminases, TSH, and so on for this weakness differential. And I think we should consider a temporal artery biopsy to begin treatment as soon as possible so that we can prevent possible complications, especially blindness.’
‘I agree.’ Joe nodded. ‘That sounds very reasonable. And it’s something that we cannot miss! It’s a good thing Mrs. Rogers came by. Hopefully, we can help her get better soon.’
I thanked him and went back to talk to Paula. I explained to her what we thought was her most likely diagnosis and she listened carefully. I ordered her labs and asked her to come back as soon as they got ready.
In the same week, she was back with a pile of papers with all of her results. A high ESR and c-reactive protein was the first thing I saw, which confirmed she was inflamed. Everything else was pretty standard, including her CK which was normal. I told her we would go through with the biopsy and explained everything about the procedure.
Fast forward a few weeks, her biopsy showed the transmural inflammation I had learned for my tests while in college. We started her on corticoids and with only a week of treatment I couldn’t believe it when I saw her again. She couldn’t stop moving her arms around.
‘It’s like I have them back, Dr. Diaz!’ She said in awe and I smiled brightly.
‘That is so good to hear, Mrs. Rogers.’
After Paula, whenever I see a patient who wants to get a ‘check-up’, I ask them why.
You’d be impressed by the answers.
…
Want to know more about Polymyalgia Rheumatica?
https://rarediseases.org/rare-diseases/polymyalgia-rheumatica/
Want to know more about Giant Cell Arteritis?
https://rarediseases.org/rare-diseases/arteritis-giant-cell/
Want to read a real case of Polymyalgia Rheumatica associated with Giant Cell Arteritis?
https://academic.oup.com/rheumap/article/4/2/rkaa049/5932453
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