Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Normocytic anaemia, Polymyalgia rheumatica, Vitiligo
Clinical narrative: ASSESSMENT AND PLAN: 1. Arthralgia after vaccination (Primary), C-Reactive Protein, High Sensitivity; Future, Rheumatoid Factor, Qual.; Future, ANA Screen, Qual., Reflex; Future, Sedimentation Rate; Future, Cyclic Citrullinated Peptide Ab, IgG; Future, CBC with Differential; Future, Comprehensive Metabolic Panel; Future, TSH, Reflex Free T4; Future, predniSONE (DELTASONE) 10 mg tablet; Take 1 tablet by mouth Daily for 30 days.  Dispense: 30 tablet; Refill: 0. 2. Vitiligo, C-Reactive Protein, High Sensitivity; Future, Rheumatoid Factor, Qual.; Future, ANA Screen, Qual., Reflex; Future, Sedimentation Rate; Future, Cyclic Citrullinated Peptide Ab, IgG; Future, CBC with Differential; Future, Comprehensive Metabolic Panel; Future, TSH, Reflex Free T4; Future, predniSONE (DELTASONE) 10 mg tablet; Take 1 tablet by mouth Daily for 30 days. Dispense: 30 tablet; Refill: 0. 3. History of autoimmune disorder: C-Reactive Protein, High Sensitivity; Future, Rheumatoid Factor, Qual.; Future, ANA Screen, Qual., Reflex; Future, Sedimentation Rate; Future, Cyclic Citrullinated Peptide Ab, IgG; Future, CBC with Differential; Future, Comprehensive Metabolic Panel; Future, TSH, Reflex Free T4; Future, predniSONE (DELTASONE) 10 mg tablet; Take 1 tablet by mouth Daily for 30 days.  Dispense: 30 tablet; Refill: 0. 4. Polyarthralgia Assessment & Plan: U information reviewed- Polymyalgia typical findings, normocytic anemia, negative autoantibodies. Laboratory findings: Acute phase reactants are elevated in virtually all patients with PMR. Head-to-head studies of the diagnostic value of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are few, but in clinical experience, the CRP is a more useful index of inflammation. The traditional laboratory finding in PMR is an elevated ESR, which ranges from mildly to markedly increased. In one study, 20 percent of patients had ESR values over 104 mm/hour [27]. Conversely, several studies have found that in approximately 5 to 20 percent of patients with PMR, the ESR is less than 40 mm/hour [28-30]. The CRP is nearly always elevated in PMR. In two reports, an elevated ESR (greater than 30 mm/hour) was noted in 92 to 94 percent of patients at the time of diagnosis of PMR, while 99 percent of such patients had an increased serum CRP level (greater than 5 mg/L) [27,31]. In another study, only 1.5 percent of patients with clinically diagnosed PMR had an ESR and CRP within normal limits (defined as less than 20 mm/hour and 10 mg/L, respectively) at the time of diagnosis [32]. The range of the CRP in PMR, like the ESR, is wide. A diagnostic cut-off value for elevations of the CRP (IE, below which the diagnosis is ruled out) has not been established, but practically speaking, a normal CRP effectively excludes the diagnosis of PMR. Other laboratory findings are nonspecific: A normocytic anemia may be present, and the white blood cell and platelet counts are usually normal, though thrombocytosis can occur as part of a general acute inflammatory response. Autoantibodies, including rheumatoid factor (RF) and anticyclic citrullinated peptide (anti-CCP) antibodies, are usually negative in PMR, and if positive, an alternative diagnosis of late-onset rheumatoid arthritis (RA) should be considered. On the other hand, it should be borne in mind that approximately 10 percent of the older adult population has a positive RF (usually at a low titer) without evidence of RA. Plan: Will get labs Since CRP elevated on labs without other concerning positive labs and patient is meeting diagnostic criteria for PMR per UTD diagnostic algorithm, will start low dose prednisone at 10mg daily due to the fact that last time he had PMR diagnosis that he developed agitation and mood changes that caused him to d/c the steroid medication. Thus will start lower than the typical recommended dosage of 15mg/daily. Will follow-up within 1 week to determine response. If in 1 week, no improvement in symptoms or no improvement in labs, would attempt to increase prednisone dose if tolerated side effects. Would also recheck labs at that point. Diagnosis and treatment of PMR.