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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
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A Case Report: A 93 Year Old Female
Presents with a 1-Month History of Hip
and Shoulder Pain, Then Develops
Hypertension
10/20/2012
Lock Haven University
Christie Slottje
A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
Abstract
Polymyalgia Rheumatica (PMR) is a disease rarely ever seen except for those in later stages of life. In
fact, the rate of the disease in people under 50 years of age is only 0.1 per 100,000 persons. Beyond the
age of 50, the rate only rises to 77 in 100,000 (Firestein, 2012.) A patient will often present with
“aches,” which can include arms, shoulders, hips, and neck. Generally the aching is worse in the
morning (Firestain, 2012.) The diagnosis of PMR is can be difficult because of the numerous diseases
that can cause aches in elderly patients. It is mostly diagnosed by its clinical features. These features, as
described in Firestein, 2012 are “ (1) aching and morning stiffness lasting half an hour or longer in the
shoulder, hip girdle, neck, or some combination; (2) duration of these symptoms for 1 month or longer;
(3) age older than 50 years; and (4) laboratory evidence of systemic inflammation such as an elevated
erythrocyte sedimentation rate (ESR).[2] Some definitions also include a rapid response to small doses of
glucocorticoids such as prednisone 10 mg/day.” Prednisone is a strong treatment that can quickly clear
up the symptoms of PMR, however, as this case will discuss, it can cause a multitude of side effects,
including dangerous hypertension (Mayo Clinic, 2010.) When a 93 year old woman appeared in our
office complaining of severe pain her arms and hips, the diagnosis of this unusual disease was only the
beginning of the battle to treat her.
Chief Complaint: Pain in arms and hips for one month
HPI: A 93 year old female, who is a known patient, presented to the office for pain her arms and hips
that has been getting worse for one month. The patient states that the pain is a 10/10 on the pain scale.
She had been seen by an orthopedic doctor who had given her an injected of cortisone in her left
shoulder the week prior. This injection gave her no relief. She describes the pain as a “grinding feeling”
with stiffness in the joints. She had also used Advil and Tylenol with minimal or no improvement in pain.
The pain is now interrupting her everyday activities, which are rather extensive for a 93 year old. The
pain is disturbing sleep and preventing her from walking. The pain is not decreased with rest, but the
patient claims that activity is unbearable. The patient also stated that the pain is intense enough that it
is causing her nausea on a regular basis.
The patient has a history of degenerative joint disease, particularly in the left shoulder, osteoporosis,
muscle spasms and episodes of acute back pain. The patient does claim that the pain she has been
experiencing for the last mouth is not the same type of pain that she has experienced in the past related
to these other problems.
The patient denies fever, chills, night sweats, headaches, changes in vision, changes in hearing, tinnitus,
dizziness, confusion, syncope, trouble swallowing, sore throat, numbness, shortness of breath, chest
pain, palpitations, cough, wheezing, abdominal pain, vomiting, diarrhea, constipation, changes in
urination or bowel movements, changes in appetite, increased thirst, sensitivity to temperature
extremes, depression or changes in anxiety.
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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
Medications:
Levothyroxin 50mcg QD
Celebrex 200 mg QD –stopped taking 30 days ago because she didn’t think it was helping
Metformin 1000mg BID
Caduet 10mg QD
Benicar 40mg QD
Lansprazole 30mg QD
Escitalopram 10mg QD
Zolpidem 10mg HS PRN
Calcium 600mg BID
Tylenol 325 mg PRN
Aleve 220mg BID
Allergies: No Known Allergies
Past Medical History
DM, type II
Hypertension
Hypothyroidism
Hyperlipidemia
Insomnia
Osteoporosis
Depression
Family History
Mother: died at age 94: CVA
Father: died age 56: DM type II and CVA
2 brothers:
84: died of cancer unknown
87: died of pneumonia
3 children:
Son, died age 39: suicide
Son, died age 62: MI, had diabetes
Son, age 70: alive with no known medical conditions
Social History:
The patient is a 93 year old widow of nearly 30 years. She lives alone, but has frequent visits
from her living son and friends. The patient admits to alcohol use when she was younger, but no longer
uses alcohol or tobacco. The patient is still active in the community and at 93 years of age still drives
herself on most days.
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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
Physical Exam
Vitals: BP: 125/60 Pulse: 84bpm RR: 18 Weight: 125lbs. Height 5’0”
General: Patient appears in good health, is in obvious pain, but has positive mood and optimistic.
Patient appears very fit for age. Patient was examined while sitting and standing in exam room.
Skin: Skin is dry, but is warm and without rash, ecchymosis, or lumps. No pitting of nails
Head: No obvious signs of trauma
Eyes: Pupils are equal and reactive to light, extraoccular movements intact, conjunctiva clear
Ears: No tenderness or discharge
Mouth: Patient wears dentures, no lesions or ulcers in mouth
Neck: Supple, non tender, no JVD or bruits
Chest/breasts: No lumps or ecchymosis, non tender to palpation
Heart: Regular rate and rhythm, S1 & S2, no murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, nontender, positive bowel sounds x 4
Musculoskeletal/Extremities: No edema or cyanosis, limited range of motion in shoulders and hips,
decreased strength in arms bilaterally
Vascular: Carotid, radial, popliteal, posterior tibial, and dorsalis pedis all +2 and equal bilaterally
Neurologic: alert to time, person, and place, no sensory deficits noted
Differential Diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Rheumatoid arthritis
Systemic lupus
Lyme disease
Urinary tract infection
Myocardial Infarction
Scleroderma
Polymyalgia rheumatica
Psoriatic arthritis
Osteoarthritis
Reactive arthritis
Fibromyalgia
Plan
1) ESR, CBK, RA Factor, CK, CKMB, Troponin
2) Continue Aleve to manage pain until lab results obtained
Lab Results:
CK 63 (26-192)
CKMB 0.7 (0.0-3.6)
Troponin <0.02 (<0.06)
Hematology all within normal limits
RA Factor: negative
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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
ESR 57 (<25)
Clinical course
Based on the results of the laboratory studies, along with the presenting signs and symptoms,
the patient was diagnosed with polymyalgia rheumatica. The following week the patient was started on
20 mg of prednisone once per day. The patient came back one week later and her pain had dropped
from a 10/10 to a 5/10, however, she was complaining of polyuria and her blood pressure was slightly
elevated (156/92). No changes were made to the treatment and she was instructed to return again in
one week.
The patient returned again after two weeks still complaining of polyuria. The pain was now a
3/10, but the blood pressure was again elevated (152/94). It was decided that steroid dose would be
reduced to 10mg per day and monitored closely. After several weeks the patient returned still
complaining of polyuria and the blood pressure was quite elevated (148/90). The prednisone was
decreased to 8mg per day and Norvasc 5mg per day was started to control the blood pressure.
On October 10, two weeks after beginning the Norvasc, the patient returned. Her blood
pressure was 142/82 and her pain was a tolerable 3/10. It was discovered after carefully reviewing the
patient’s medications that she had misunderstood the instructions from the pharmacy and was taking
only 5mg prednisone per day. Because this dose seemed to control the pain and not cause out of
control hypertension, it was decided to keep the patient on this dose. The patient reported that her
polyuria had lessened to a more manageable level as well.
Discussion:
When this 93 year old female presented with aching pain in upper and lower extremities with
nausea, the different diagnosis could be endless. When dealing with patients in the extreme of age it
can be difficult to pinpoint the cause of vague symptoms like these. It is important to consider life
threatening causes, such as a myocardial infarction, which in elderly woman can have nontraditional
symptoms. Infections also need to be included in the differential, especially in elderly patients where
the symptoms can be misleading. Of course the usual suspects should also be looked at; arthritis,
systemic lupus, and even scleroderma are known to cause pain in multiple joints (Richie, Frances, 2003).
With such a large differential diagnosis, it is important to choose diagnostic tests carefully.
When a patent with known osteoporosis presents with pain, an xray may be considered, however
fractures did not fit this patients description of pain. There are many rheumatologic tests that can be
ordered, such as an ANA (Richie, 2003). This may have been ordered if a diagnosis and treatment had
not been successful in the first round of tests that were ordered on this patient. In this case a diagnosis
was made based on the ruling out other diseases with the troponin, CK, CKMB, and hematology. The
diagnosis of PMR was supported by the ESR as well as the clinical presentation of this patient.
In this case, the patient presented with a traditional clinical picture for polymyalgia rheumatica.
She is an elderly female, who was in overall good health previously. The average age for onset of PMR is
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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
79 years old and it is more common in women than men. The patients are usually healthy before the
onset, which is usually gradual over a month, but can be quicker like in this case. Another feature of
PMR is that it is relieved with a 10-20mg daily dosage of prednisone, as in this case (Firestein, 2012). In
this patient, another seemingly more dangerous problem was created by the treatment. This patient
developed corticosteroid induced hypertension. Although this further complicated the treatment of this
patient, the symptoms were eventually controlled and balance was obtained between treatment of the
PRM and controlling the hypertension.
Summary
This 93 year old female patient presented with severe achy pain in arms and hips along with
nausea. These symptoms could lead to a long line of tests and misdiagnoses if a good physical and
history were not obtained. In this case the diagnosis was quickly made; however, the case was further
complicated by steroid induced hypertension. When facing a difficult differential diagnosis, it is
important to consider both common diagnoses as well as rare conditions.
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A Case Report: A 93 Year Old Female Presents with a 1-Month History of Hip and
Shoulder Pain, Then Develops Hypertension
References
Firestein, G. S., Budd, P. C., Gabreial, S. E., McInnes, I. B., O’Dell, J, R. (2013). Giant Cell Arteritis,
Polymyalgia Rheumatica, and Takayasu's Arteritis. Kelley’s Textbook of Rheumatology, 9th ed., chapter
88. Philadelphia: Elsevier Saunders.
Rickie, A. M. Diagnostic Approach to Polyarticular Joint Pain (2003). American Family Physician.
15;68(6):1151-1160.
Weigh the benefits and risks of corticosteroids, such as prednisone, when choosing a medication. (2010).
Mayo Foundation for Medical Education and Research (MFMER). Retrieved from
http://www.mayoclinic.com/health/steroids/HQ01431.
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