Around 20 years ago, while I was still doing outpatient medicine, a 65-year-old construction worker came as a new patient with diffuse pain.  His story gave many clues.

3 months prior, he was working on construction in the Mobile area.  One task of his involved carrying concrete blocks.  One day he could no longer grip the blocks because of hand pain.  This pain did not resolve with NSAIDs.  He had to stop working.

Over the next months he developed more pain including his shoulders and hips.  As he walked into the examine room, he was almost shuffling and clearly was uncomfortable.  He had already seen 3 or 4 physicians who had tried a variety of pain meds without success.

As I shook his hand, he could not squeeze at all because of the pain.  On further examination, his MCP and PIP joints all had synovitis (boggy, spongy, painful) symmetrically.  He had difficulty touching the top of his head, but this was clearly pain related as his strength was excellent.

He felt that he had had low grade fevers and general malaise.

I considered some diagnoses, ordered some tests and then reconsidered his condition.

What tests do you want?  What diagnosis do you think he had?