Patient With Fatigue

EM is a 74-year-old male with a history of rheumatoid arthritis (RA) who presents in the clinic with a complaint of fatigue. EM is ambulatory with a walker and recently has had intermittent flare-ups of his rheumatoid arthritis (RA) disease activity, with increasing pain and swelling in his affected joints. His energy has been declining over the past few months, so he thought it was a good time to come in for follow-up laboratory testing and reassessment of his medications. Most troublesome, he has fainted twice in the past 2 weeks, which resulted in falls onto his carpeted floor. He is afraid to go out into public and even more afraid to drive his car. He has also had some chest pains with exertion. He is eating and sleeping okay, although he does sleep better if his head is elevated on a few extra pillows. He lives alone and gets meals delivered by a local organization.

Past Medical History

· RA for 35 years, affecting hands, feet, knees, hips, and cervical spine

· Systolic hypertension

· Presbycusis

Medications

· Ibuprofen, 600 mg three to four times per day as needed

· Methotrexate, 7.5 mg weekly

· Atenolol, 25 mg daily

· Hydrocodone/acetaminophen, 5 mg/500 mg every 6 hours as needed for pain

Physical Examination

· Height: 71 inches; weight: 160 lbs.; BMI: 22.3; blood pressure: 162/60; pulse: 84; respiration rate: 16; temperature: 98.6 °F

· Well-developed, well-nourished elderly male in no distress; pale

· Lungs: bibasilar rales

· Heart: regular rate and rhythm, grade 3/6 systolic murmur, audible S3; positive carotid bruit on the left

· Abdomen: no masses, nontender

· Rectal: prostate 3+ enlarged, hemoccult negative brown stool

· Extremities: marked ulnar deviation of MCP and IP joints in both hands

Labs and Imaging

· Hemoglobin: 8.9 g/dL

· Mean corpuscular volume (MCV): 80 fL

· White blood cell count: 10.7 × 10 9 /L

· Platelets: 250,000/L

· Reticulocyte count: 0.8%

· Ferritin: 415 mcg/L

· Electrocardiogram: no acute findings; some evidence of left ventricular hypertrophy

Discussion Questions

1.What is EM’s diagnosis?

2.What is the underlying pathophysiology of EM’s condition?

3.What is the best therapeutic approach to the treatment of EM’s condition?