Transcript Journal Club

Clinical Correlations
The NYU Langone Online Journal of Medicine
http://clinicalcorrelations.org
NYU Medicine Grand Rounds
Clinical Vignette
Matthew Lee, MD
PGY-2
3/12/14
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•The patient is a 69 year-old woman who
returned to Rheumatology clinic with
worsening bilateral knee pain for the past
year.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Since 2004, the patient has had bilateral knee
pain and stiffness
•Over 3 years, the patient described
progressive worsening of the above symptoms
•She was followed by her primary care
physician who initially prescribed NSAIDs and
physical therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Despite the prescribed therapies, her
symptoms progressed to become physically
limiting.
•In 2009, she was referred for Rheumatology
consultation
•Her initial x-rays were notable for advanced
bilateral medial joint space narrowing, varus
deformity, and large osteophytes consistent
with osteoarthritis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Because of her symptoms and imaging,
surgery was discussed, however the patient
declined.
•In addition to NSAIDs and physical therapy,
she received intra-articular steroids and
viscosupplementation with hylan G-F 20
injections in 2011-2012.
•Due to worsening symptoms, she underwent a
series of hyaluronic acid injections that finished
in 12/2012.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Despite the hyaluronic acid injections, she
noticed minimal relief and continued to have
severe knee pain over the past year before
returning to Rheumatology clinic this January.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History/Past Surgical History
•Thyroid cancer with thyroidectomy and radiation
therapy in 2007
•Obesity
•Osteoarthritis of bilateral knees
•Osteoporosis with history of wrist fracture (2009)
•Allergies:
•No Known Drug Allergies
•Medications:
•Ibuprofen as needed
•Levothyroxine 112 mcg by mouth daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Family History:
•Mother had osteoporosis and history of a hip
fracture
•Social History:
•Remote history of tobacco use (quit over 25
years ago)
•Social alcohol use
•Retired nurse; now working as real estate
agent
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
Vital signs were unremarkable, however BMI was
stable at 30 kg/m2.
General: Well-appearing woman with a noticeable
antalgic gait bilaterally.
Knees: bilateral crepitus and mild swelling; no
warmth. Pain elicited near full flexion
Hands: Heberden’s nodes in multiple distal
interphalangeal joints of bilateral hands
Remainder of exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Synovial Fluid Results
•Appearance: clear, yellow
•Cell Count: 312 nucleated cells (48%
lymphocytes, 39% macrophages, 0% polys)
•No crystals
•Negative bacterial culture
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Diagnosis and Treatment Plan
Diagnosis: progressive tricompartmental
osteoarthritis
• Intra-articular injection of
methylprednisolone
• Physical Therapy
• Weight loss encouragement
• Consideration of total knee arthroplasty
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS