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Old 04-17-2012
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Question Arthritis and Nodules!

A 64-year-old diabetic patient presents with a 13-months history of episodic pain, swelling, and stiffness in some of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of his fingers. During these episodes, he has significant morning stiffness. He says he has no other joint problems or back pain. A review of systems is otherwise unremarkable.
On physical examination, he has swelling and tenderness of some MCP and PIP joints in an asymmetrical distribution. The rest of the physical examination is normal, with no clinical evidence of joint deformities, and no evidence of psoriasis of the skin or nails. Over the course of the next 2 years, nodules appear over the fingers and, recently, over the Achilles tendons.
What is the most likely cause of his problem?

A Gouty Tophi
B Rheumatoid nodulosis
c Tuberous Xanthoma
D Calcinosis cutis
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Answer is C
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rheumatoid nodules...but doubting it cant be that simple
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Old 04-17-2012
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tuberous xanthoma is associated with hyperlipidemia
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Type 2 hyperlipidemia is associated with metabolic syndrome
and M S includes DM
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but why then joint pains?
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Default C)

I would have gone with B) Rheumatoid Nodulosis just because the question states that the patient has Morning stiffness. Morning stiffness that improves with use is particularly seen in Rheumatoid Arthritis. However, there is no joint problems or deformities which are characteristically seen in Rheumatoid arthritis .. such as ulnar deviations, boutonniere's or swan neck deformities.

I think the nodules that formed over his fingers were heberden's (DIP)0 and bouchards (PIP) but those are related to Osteoarthritis.

Since there is Achilles involvement, its a diabetic patient and this is a chronic disorder, I will go with Tuberous Xanthoma's given that he developed hyperlipidemia in the course...
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just not because it says morning stiffness but because it involves the PIPs and MCP joints this type of joint involvement very characteristic of RA
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Quote:
Originally Posted by usmlemydream View Post
jut not because it says morning stiffness but because it involves the PIPs and MCP joints this type of joint involvement very characteristic of RA
Yeah that's what I thought but don't you have to have some sort of joint deformities in it ?




[Btw, you never posted an answer for this question: http://www.usmle-forums.com/usmle-st...-meal-you.html Please post an answer as I would really like to know whats the right option! ]
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its confusing
achilles tendon xanthoma will not occur in RA
but the clinical picture is so very RA
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And additionaly there is asymetric involvement
In RA more or less symetric pattern exists
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joint deformities will occur but it occurs later the disease course
if we had to diagnose RA only based on joint deformities
what would be the point of finding the specific joints it involved
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yep i missed on RA being symetrical......
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a friend of mine told me that for step 1, if u ever see an "easy" answer on the exam, dont be afraid and just choose it!

i would say RA
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I would say Xanthomas, just because the nodules are on a joint and there is no deformity after 2 years.

and also the minute I read Achilles tendon nodules it came to my mind, then I checked Goljan again and found this

Familial hypercholesterolemia
(1) Autosomal dominant (AD) disorder
(2) Deficiency of LDL receptors
(3) Clinical findings
(a) Premature coronary artery disease and stroke
(b) Tendon xanthomas (Fig. 9-2A)
Achilles tendon xanthoma: pathognomonic for familial hypercholesterolemia
Cholesterol deposit located over tendons (e.g., Achilles) and extensor surfaces of joints.

Hope it helps
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Old 04-18-2012
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Quote:
Originally Posted by ingridb84 View Post
I would say Xanthomas, just because the nodules are on a joint and there is no deformity after 2 years.

and also the minute I read Achilles tendon nodules it came to my mind, then I checked Goljan again and found this

Familial hypercholesterolemia
(1) Autosomal dominant (AD) disorder
(2) Deficiency of LDL receptors
(3) Clinical findings
(a) Premature coronary artery disease and stroke
(b) Tendon xanthomas (Fig. 9-2A)
Achilles tendon xanthoma: pathognomonic for familial hypercholesterolemia
Cholesterol deposit located over tendons (e.g., Achilles) and extensor surfaces of joints.

Hope it helps

I'm a little unclear- Would there be swelling and tenderness?
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Old 04-18-2012
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Mmm i dont think so.
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Quote:
Originally Posted by Valkoff View Post
I'm a little unclear- Would there be swelling and tenderness?
Just read up on it. Tuboeruptive xanthomas can present with inflammation, so c Tuberous Xanthoma seems likely to me.
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  #19  
Old 04-20-2012
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Correct Answer

Rheumatoid Nodulosis is the correct answer.

[MCP + PIP]
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  #20  
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Quote:
Originally Posted by Desos View Post
Rheumatoid Nodulosis is the correct answer.

[MCP + PIP]
I guess we missed the obvious answer because we were over-thinking.
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  #21  
Old 04-21-2012
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my friend who did the exam told me a piece of advice that i think was pretty valuable... suppress that inner genius in you and choose the simple answer you know to be true!
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  #22  
Old 04-21-2012
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Quote:
Originally Posted by Desos View Post
Rheumatoid Nodulosis is the correct answer.

[MCP + PIP]
Could u plz post the explanation to this question

Sorry for misleading fellows
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