HPI

• A 35yo receptionist presents to your office complaining of intermittent episodes of pain, stiffness, and swelling in both hands and wrists for approximately 1 year. These episodes last for a few weeks and then resolve. Recently, though, she noticed similar symptoms in her knees and ankles. She is finding it harder to get of bed in the morning and harder to complete her work duties due to joint pain and stiffness. The stiffness lasts several hours before improving. She also reports malaise and easy fatigability for the past few months, but she denies any fever, chills, skin rashes, or weight loss.

Physical Exam

• Vitals: 120/70, 82 bpm, 14 br/min• HEENT/Cardio/Pulm/Abd exams normal• Skin: No rashes• MSKL: blt swelling, redness, and tenderness of

PIP and MCP joints, wrists, and knees

Differential Diagnosis

• Rheumatoid Arthritis• Osteoarthritis• SLE• Hypothyroidism• Viral Polyarthritis• Reactive Arthritis

LabsCMP

Na 140

K 4

Cl 100

CO2 22

BUN 20

Cr 1

Glu 95

Ca 9.5

Total Protein 7.6

Albumin 4

Total Bilirubin 0.7

Alkaline Phosphatase 71

AST 25

ALT 40

UANo microalbuminuria or RBC

TSH2.2

ESR75

Radiology

• Note: You can see synovial inflammation and ulnar deviation. The thumb exhibits Boutonniere’s deformity with PIP flexion and DIP hyperextension.

Pathology

• Chronic lymphocytic and plasma cell infiltration (blue areas) beneath articular nodular proliferation creating a pannus that will eventually erode the remaining articular cartilage

Gross Picture

• Swan neck deformity showing PIP hyperextension with DIP hyperflexion