Differential Diagnosis

The patient's complex presentation of migratory arthritic symptoms, progressive bilateral lower extremity swelling, intermittent blurry vision, and history of elevated blood pressure, along with concerns about an undiagnosed autoimmune condition, necessitates a broad differential diagnosis. The following categories outline potential diagnoses:

• Single Most Likely Diagnosis
  • Rheumatoid Arthritis (RA): Given the patient's longstanding history of migratory arthritic symptoms since age 25, RA is a strong consideration. The symptoms of progressive bilateral lower extremity swelling and increased pain, along with a history of episodes severe enough to cause bedridden periods, align with the potential systemic involvement seen in RA.
• Other Likely Diagnoses
  • Systemic Lupus Erythematosus (SLE): The patient's concern about lupus, combined with symptoms such as arthritic pain, intermittent blurry vision (which could indicate retinal vasculitis or other ocular manifestations of SLE), and a history of possible pericarditis ("paracritis"), makes SLE a plausible diagnosis.
  • Gout: The patient's description of severe, episodic joint pain and swelling, particularly affecting the toes, is suggestive of gout. However, the absence of reported trauma or crystal confirmation makes this less certain.
  • Psoriatic Arthritis: The chronic redness of the left hand, worsening in the summer and present for 35 years, could be indicative of psoriasis, and thus psoriatic arthritis should be considered, especially given the patient's arthritic symptoms.
• Do Not Miss Diagnoses
  • Vasculitis (e.g., Polyarteritis Nodosa, Giant Cell Arteritis): Given the patient's complex presentation, including possible pericarditis and episodes of severe symptoms, vasculitis must be considered due to its potential for serious complications if missed.
  • Sjögren's Syndrome: This autoimmune disorder can present with arthralgias, dry eyes (potentially causing blurry vision), and other systemic symptoms, making it a "do not miss" diagnosis due to its potential impact on quality of life and the eyes.
  • Amyloidosis: Although less common, amyloidosis can cause systemic symptoms including arthralgias, swelling, and potentially vision changes due to amyloid deposits in various tissues, making it critical not to overlook.
• Rare Diagnoses
  • Relapsing Polychondritis: This rare autoimmune disorder affects cartilage and could explain some of the patient's symptoms, including arthritic pain and potential eye involvement.
  • Multicentric Reticulohistiocytosis: A rare condition characterized by skin and joint lesions, which could potentially explain the chronic redness of the hand and arthritic symptoms.

Recommended Labs and Tests

• Complete Blood Count (CBC) with differential
• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) to assess inflammation
• Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibody (Anti-CCP) for RA
• Antinuclear Antibody (ANA) test for SLE and other autoimmune disorders
• Uric acid level to evaluate for gout
• Blood urea nitrogen (BUN) and creatinine to assess renal function
• Urinalysis to check for proteinuria or hematuria
• Consider imaging studies (e.g., X-rays, ultrasound) of affected joints
• Ophthalmologic examination to assess for potential eye involvement
• Biopsy of affected skin or tissue if necessary to confirm specific diagnoses (e.g., vasculitis, amyloidosis)

Given the patient's complex presentation and the need for a definitive diagnosis, referral to a rheumatologist for further evaluation and management is strongly recommended.