Mrs. L., teacher

• 55 years old
  
• Single mother of three adopted sons ranging in age from 12-20 years
  
• Past history includes significant joint symptoms including back pain, neck and knee pain with stiffness, and pain in the small joints of her hand.
  

Questioning reveals:

• Pain radiates down the knee and worsens as the day progresses but improves when reclining
  
• While pain is felt mostly in the groin area, it sometimes seems to travel toward her right knee
  
• Mrs. L. is not very stiff but has some trouble walking just as she rises from sitting
  
• Mrs. L. is really at her best in the morning after a good rest.
  

Past history:

• Over the years she has had low back pain, neck pain with stiffness, knee pain with stiffness, and pain in the small joints of her hands. She has responded well to short courses of full dose NSAIDs.
  
• Presented five years ago with:
  
  • Pain in the distal interphalangeal (DIP) joints of both hands
  • Heberden's nodes. Hard, bony and sometimes tender nodules may be seen in OA of the DIP joints (Heberdens) and/or PIP joints (Bouchards).
  • Diagnosed with OA.
    
• Hospitalized seven years ago with inflammatory polyarthritis
  
• 13 effusions and extensor carpi ulnaris tenosynovitis were documented
  
• Results of lab tests showed:
  
  • ESR 44
    
  • ANA negative
  • RA negative
    
• Treated with:
  • Diclofenac
  • Omeprazole
    
  • Physiotherapy
    
  • pool therapy
    
• She responded well to the management plan and after six months was able to discontinue medication, using pool therapy to maintain her fitness level. She also self-medicates with glucosamine.