Identifying these nodules?

This is a 39 yr old female who comes to the clinic for chronic complaints of joint pain and fatigue.

She says she has had joint pain and fatigue for years. She says getting out of bed every morning is a challenge, she reports of stiffness in the morning and says hot showers do help. No reports of joint pain getting better as the day goes on. She does admit that the cold weather makes her joints much more painful. She has tried otc NSAIDS but they haven't really helped her. She takes natural supplements for boosting energy. She has not tried any form of steroids in the past. She has denied fever/chills with these symptoms.

She was tested for autoimmune etiologies in the past with her Rheumatoid Factor negative 2012.

She had an ANA, along with CCP with anti-smith antibodies last week with us and all of them were negative. CBC only showed a mild elevation in RBC, low MCV (she has hx of iron def. anemia) and low MCH.

She does complain of nodules on her fingers (see pics) and toes that she has noticed for a few yrs. She says these are painful and not have subsided at all. She doesn't have any drainages from these nodules. On palpation, these nodules feel like hard calluses, in some of the digits, it almost feels like the bone is right under the skin.

She does have a hx of bowing of her legs as well. She has always had this as a child but was never diagnosed with any form of bone deformity.

Pmhx: Endometriosis, Mitral/Triscuspid regurg.

Social hx: Doesn't smoke, drinks ETOH occ, doesn't use any illicit drugs. (smoked weed during college). No hx of IV drug abuse.

Thoughts?

Additional Cases

Young woman in her thirties presents with a case of body aches (primarily in her legs, knees, and back), headache, cough, fatigue, and rash.

She had a low grade temp of 99.9 but says she had the flu. She did vomit once earlier in the day but wasn’t sure if it was related to this or her vitamin that she takes. Vitals stable at office but she does appear to be fatigued and pale. Recommendations on any labs I should run?

60-year-old woman presents with extreme fatigue and malaise described "as if she had fever" for four months.

She gets better with NSAIDS (eg ibuprofen) and gets worse again as soon as she stops taking them. Labs show no abnormalities. I referred her to a rheumatologist thinking about an inflammatory disease.

A 28 year old woman presents to office.

She is healthy but over the past few months has been extremely tired. She has an increase in headaches recently.

1. What would you focus your assessment on?
2. What labs would you get? And why?
3. Three different diagnosis based on her symptoms and labs?
   • WBC 7.4
   • RBC 4.48
   • Hgb 11.7
   • HCT 32.0
   • MCV 77.6
   • MCH 30.4
   • MCHC 34.3
   • Platelets 215
   • Glucose 101
   • NA 130
   • K 4.2
   • CL 97
   • CO2 25.8
   • BUN 16
   • Creat 0.8
   • Alk phos 110
   • T bill 1.2
   • AST 33
   • ALT 29
   • TSH 4.84
   • Free T4 1.02