Thursday, September 29, 2016

A 70-Year-old Woman Presents with Pain and Swelling in the Joints of Both Hands

A 70-year-old woman presents with pain and swelling in the joints of both hands, which impedes her normal activities. Her pain is better in the morning after resting and worse after she has been working with her hands. She denies stiffness. On examination, you find bony enlargement of some distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints on both hands ( shown in picture above) Radiographs confirm the presence of Heberden and Bouchard nodes. She begins taking 1 g of acetaminophen twice a day and has significant improvement in her pain and function.

What is the diagnosis?

Osteoarthritis.

What is the differential diagnosis for a patient presenting with musculoskeltal pain ? 

Musculoskeletal pain can also be caused by:

• Connective tissue diseases (scleroderma and lupus) that have other specific systemic signs.
• Fibromyalgia—Pain at trigger points instead of joints.
• Polyarticular gout—Erythematous joints and crystals in joint aspirate
• Polymyalgia rheumatica—Proximal joint pain without deformity, elevated ESR.
• Seronegative spondyloarthropathies—Asymmetric joint involvement, spine often involved.
• Reactive arthritis—History of infection, sexually transmitted disease, or bowel complaints. The patient may have conjunctivitis, iritis, urethritis in addition to joint pain and arthritis.
• Rheumatoid arthritis—Symmetric soft-tissue swelling in distal joints, stiffness after inactivity, positive rheumatoid factor. Ulnar deviation of the fingers at the MCP joints is a distinct finding in
rheumatoid arthritis.
• Bursitis—Pain at one site, often increased with direct pressure.

How would you manage a case of Osteoarthritis? 

Non pharmacologic Options for Osteoarthritis include: 
  • Weight loss (if overweight)
  • Aerobic exercise
  • Range-of-motion exercises
  • Muscle-strengthening
  • Assistive devices for walking
  • Safe shoes
  • Physical and Occupational therapy
  • Joint protection such as braces
  • Assistive devices for activities of daily living
  • Social support
Pharmacologic Options for Osteoarthritis include: 

1. Oral Medicines :
• Acetaminophen
• COX-2-specific inhibitor
• NSAID plus a proton pump inhibitor
• Opioids (e.g. hydrocodone)
• Tramadol

2, Topical Medicines: 
• Methylsalicylate
• Topical NSAID (e.g diclofenac gel)

3. Intraarticular
• Glucocorticoids (e.g. triamcinolone)
• Hyaluronic acid

1 comment:

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