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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