nyu medical grand rounds clinical vignette joseph shin, md tuesday, april 3, 2012 u nited s tates d...

NYU Medical Grand Rounds Clinical Vignette

Joseph Shin, MD

Tuesday, April 3, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•57 year-old Hispanic woman with 6-7 years of worsening hand and wrist pain.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•Usual state of good health until ~2004-5

•New R ankle and L elbow pain

•Over 6-7 years, the pain progressed to involve bilateral wrists, hands and fingers, exacerbated by cold and repeated movement, but without tenderness, swelling or morning stiffness

•Self-treated with ibuprofen prn but with diminishing efficacy over the last several months.

Additional History•Past Medical History:

•Hypertension

•Past Surgical History:•Cesarean section x2

•Social History:•Never smoker. Denies alcohol or illicit drug use.•Immigrated from the Dominican Republic in 1989•Employed as a seamstress

•Family History:•No family history of autoimmune disease or inflammatory arthritis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Allergies: •NKDA

•Medications:•Ibuprofen 400mg TID prn

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•Obese, well-appearing woman

•Vital Signs:

• T:97.8F BP:130/70 HR:80 RR:16 and SaO2: 100% room air

•Bilateral wrists and R ankle with effusions and tenderness with decreased range of motion

•Tenderness in bilateral proximal interphalangeal joints

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC•WBC 9900, Hg 10.6 g/dL, Plt 329,000•N 72%, L 20%, Monos 7%, Eos 1%

•Basic metabolic and hepatic panels: normal

•ESR 69 mm/hr (0-20)•CRP 52 mg/L (0.2-3.0)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•Rheumatoid Factor: 792 IU/mL (<15)•Anti-CCP IgG Ab: >250 units (<20)•ANA positive (1:640)

•ds-DNA: <1 (negative)•SS-A/SS-B Ab <1.0 (negative)•RNP Ab >1.0 (negative)

•Hepatitis B sAg/sAb and HCV Ab: negative

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Hand Xrays

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Wrist Xrays

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Moderately severe rheumatoid arthritis with evidence of erosive disease

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was started on prednisone 10mg daily, methotrexate 7.5mg weekly and folic acid 1mg daily.

• Over several weeks, the patient’s joint pain and swelling improved

• Prednisone was tapered down to 5mg every other day.

• Methotrexate was titrated up to goal dose of 20mg weekly.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Over the following 6 months the patient reported resolution of all joint swelling and pain except in bilateral wrists resulting in

5-6/10 pain and difficulty with work as seamstress.

• Despite clinical improvement, inflammatory markers remained elevated

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• After extensive counseling on options for additional medication, the patient agreed to start sulfasalazine, refusing injectable anti-TNF agents.

• Over several weeks, the patient’s sulfasalazine was titrated up with improvement in the patient’s symptoms.

Clinical Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Moderately severe rheumatoid arthritis

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS