NYU Medical Grand Rounds Clinical Vignette

Sarah Baron

PGY 3

October 25, 2011

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

The patient is a 54 year old Bengali woman presenting with one year of pain in all finger joints, worst in her right thumb metacarpophalangeal joint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient experienced finger joint pain and stiffness for about one year, worse in the morning for about 3-4 hours but persistent throughout the day•The pain was most noticeable in the right thumb•Washing her hands in hot water improved the stiffness•The patient presented to the outpatient clinic requesting pain medication and help with this stiffness

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Diabetes

•Past Surgical History:•Tubal Ligation

•Social History:•Lives with husband, works as a daycare provider•Moved from Bangladesh 22 years ago and has not returned

•Family History:•No significant family history

•Allergies: •No Known Drug Allergies

•Medications:•Acetaminophen 500mg as needed for pain

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: Middle aged woman appearing her stated age, sitting comfortably in no apparent distress

•Vital Signs: T: 97.8 BP: 121/82 HR: 72 RR 12 and O2 sat: 97% on room air

•Heberden’s Nodes were appreciated in the distal index and middle fingers bilaterally

•Tenderness to palpation over the right first metacarpophalangeal joint

•Remainder of the Physical Exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•Basic Metabolic panel: Glucose of 124•Remainder of basic was within normal limits

•The CBC and Hepatic panel were within normal limits•Anti Nuclear Antibody testing was negative•Rheumatoid Factor testing was negative•Anti-Neutrophil Cytoplasmic Antibody was negative•C-reactive Protein was 0.43 (normal 0.215-3.0)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•X-Ray of Hands: Left fifth proximal interphalangeal joint osteophyte. No joint space narrowing and no erosions

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Osteoarthritis of the bilateral middle and index fingers as well as right thumb metacarpophalangeal joint

Differential Diagnosis also included Rheumatoid Arthritis

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was started on Ibuprofen 600mg every 8 hours as needed for pain

• She was sent to Occupational Therapy

• The patient returned to the outpatient clinic 6 weeks later with markedly improved symptoms

• She continued to use ibuprofen as needed for pain

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Osteoarthritis of the right thumb metacarpophalangeal joint as well as the bilateral index and middle finger distal interphalangeal joint

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS