Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Sarah Baron
PGY 3
October 25, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
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
Working Diagnosis
Osteoarthritis of the bilateral middle and
index fingers as well as right thumb
metacarpophalangeal joint
Differential Diagnosis also included
Rheumatoid Arthritis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Osteoarthritis of the right thumb
metacarpophalangeal joint as well as the
bilateral index and middle finger distal
interphalangeal joint
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS