A 48-year-old man presents with history of joints pain. Asymmetric, involving the proximal and distal small joints of the Lt hand, the Rt knee, and right elbow. Pain, swelling, & stiffness. Joints are red & warm to the touch. Morning stiffness is moderate. Physical examination reveals nails pitting & separation from the nail bed. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 42 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis?
1. Degenerative joint disease (asteoarthritis) 2. Rheumatoid arthritis
3. Pseudogout
4. Psoriatic arthritis
5. Septic arthritis.
It looks like psoriatic arthritis, from the involvement of DIP, nail pitting and onchylosis...but with red, warm and raised ESR, may be septic arthritis. psoriasis is also inflamatory so it may have raised ESR..but septic arthritis is usually monoarthritis.
A 48-year-old man presents with history of joints pain. Asymmetric, involving the proximal and distal small joints of the Lt hand, the Rt knee, and right elbow. Pain, swelling, & stiffness. Joints are red & warm to the touch. Morning stiffness is moderate. Physical examination reveals nails pitting & separation from the nail bed. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 42 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis? 1. Degenerative joint disease (asteoarthritis) 2. Rheumatoid arthritis 3. Pseudogout 4. Psoriatic arthritis
5. Septic arthritis.
Osteoarthritis - wouldn't produce nail changes, ESR would be normal. Also, it's in weight bearing joints as well as prox and distal IF joints.
RA - Although RF is not necessary, for USMLE purposes it usually is. Would have longer morning stiffness. No nail involvement.
Pseudogout - usually presents in knee, if not, still mono- o pauciarthritis. No nail involvement. ESR could be elevated depending if secondary.
Septic arthritis - it's a monoarthritis, would have more general symptoms, and ESR would be even higher.
Remember the "pencil in a cup" deformity!
Nail lesions: the typical one is nail pitting, but also seen: separation of the nail from the nail bed, cracking, loss of the nail, etc.
Nail changes in psoriasis vary from little pits in your nails, loosening of the nail to Crumbling of thenail,severe psoriatic nail disease can lead to functional and social impairments if left untreated.
Erosive disease frequently occurs in patients with either DIP involvement or progressive deforming arthritis and may lead to subluxation and, less commonly, to bony ankylosis of the joint.
Erosion of the tuft of the distal phalanx, and even of the metacarpals or metatarsals, can progress to complete dissolution of the bone. Although this form of acro-osteolysis is not diagnostic, it is highly suggestive of psoriatic arthritis.
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