DONNA Reece, MD, Chief Resident in Medicine, Jewish Hospital of St Louis: A 65-year-old woman presented as an outpatient with a five-month history of pain and stiffness involving her neck, shoulders, and hips. Her symptoms had gradually increased in severity. At her initial visit she described having several hours of morning stiffness daily and reported difficulty in rising from a chair. She denied any joint swelling, fever, rash, weight loss, headaches, or residual disturbances. Her medical history was notable for hypertension, hyperuricemia, and a bipolar affective disorder. Surgical procedures included a frontal lobotomy 27 years earlier and bladder repair four years earlier. Her current medications were lithium carbonate, methyldopa, and allopurinol.
On physical examination, she was well developed with a blood pressure of 140/80 mm Hg, a heart rate of 88 beats per minute, and temperature of 36.8 °C. The cardiac examination was notable for a grade 2/6 systolic ejection