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  #1  
Old 06-04-2011
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Rheumatology/Orthopedics How would you investigate this knee problem!

A 53-year-old woman is evaluated for a 3-month history of bilateral knee pain on ambulation. Her pain is more notable in her right knee. She has approximately 15 minutes of stiffness each morning. She has swelling of the proximal and distal interphalangeal joints. She does not have fever, rash, photosensitivity, or oral ulcers. Her sister has systemic lupus erythematosus.

Musculoskeletal examination reveals no redness or palpable synovial swelling, but she has bilateral bony hypertrophy at the third and fourth distal and proximal interphalangeal joints. Range of motion elicits bilateral knee crepitus. There is evidence of a small right knee effusion.

Which of the following studies will be most useful in establishing this patient's diagnosis?

A Erythrocyte sedimentation rate
B Antinuclear antibody assay
C Rheumatoid factor assay
D Anti–cyclic citrullinated peptide antibody assay
E No additional studies
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  #2  
Old 06-05-2011
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D Anti–cyclic citrullinated peptide antibody assay
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  #3  
Old 06-05-2011
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I think it should be Ana !!!rheumatoid does not involve the distal interphalangeal joints !!!so I am thinking more on the lines of lupus !!
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Old 06-05-2011
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Quote:
Originally Posted by Lakshay View Post
I think it should be Ana !!!rheumatoid does not involve the distal interphalangeal joints !!!so I am thinking more on the lines of lupus !!
correct, Rheumatoid does not involve the distal
but ANA would not establish the diagnosis of Lupus either? it is not specific
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Old 06-05-2011
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Considering the asymmetric involvement of knee joint and involvement of proximal and distal interphalangeal joints along with bone hypertrophy (which are features of ostearthritis 1.bony hypertrophy could be heberden and Bouchard nodes 2.morning stifness less than 20 30 min 3.the involvement of dip )I am thinking that it can be osteoarthritis too but esr Is a very non specific investigation inthis case so the question does not have enough options I think :-)
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Old 06-05-2011
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Quote:
Originally Posted by Lakshay View Post
Considering the asymmetric involvement of knee joint and involvement of proximal and distal interphalangeal joints along with bone hypertrophy (which are features of ostearthritis 1.bony hypertrophy could be heberden and Bouchard nodes 2.morning stifness less than 20 30 min 3.the involvement of dip )I am thinking that it can be osteoarthritis too but esr Is a very non specific investigation inthis case so the question does not have enough options I think :-)
thanks,
my final answer = infected knee joint of a patient with history of osteoarthritis???
my next step would be: (Aspiration of the knee joint--> gram stain and culture, etc..) ESR, CBC with differential

I like ordering ESR which could also differentiate between the seronegative arthropathy vs ANA positive rheumatologic disease. Psoriatic arthritis also involves the DIP??
I thought about the osteoarthritis option as well, but the morning stiffness threw me off. if the knee was infected (previously damaged by the osteoarthritis) then patient would have had fever??
Her sister having the Lupus, makes me question autoimmune disease?

you know what they say, if anything looks weird, it could always be LUPUS.
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Old 06-05-2011
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There is involvement of DIP in psoriatic arthritis and ostearthtis has morning stiffness for less than 30 min
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99er (06-05-2011)
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Old 06-05-2011
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Quote:
Originally Posted by Lakshay View Post
There is incolvement of dip in psoriatic arthritis and ostearthtis has morning stiffness for less than 30 min
thank you,
The question asked:
Which of the following studies will be most useful in establishing this patient's diagnosis?

if we look at all the answers:
A Erythrocyte sedimentation rate (all it tells us is that there is inflammation, it does not establish any diagnosis)
B Antinuclear antibody assay (may classify the two major categories of arthritis into seronegative vs seropositive, but it certainly does not establish diagnosis)
C Rheumatoid factor assay (non-specific for Rheumatoid arthritis and will not establish a diagnosis.)
D Anti–cyclic citrullinated peptide antibody assay (will help in establishing the diagnosis of Rheumatoid, but the patients presentation is not consistent with rheumatoid).
E No additional studies ( these cheap nerds that makes make questions love to do nothing. "it is clinical diagnosis") I won't be surprised if that is the answer.
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Old 06-05-2011
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Quote:
Originally Posted by 99er View Post
thank you,
The question asked:
Which of the following studies will be most useful in establishing this patient's diagnosis?

if we look at all the answers:
A Erythrocyte sedimentation rate (all it tells us is that there is inflammation, it does not establish any diagnosis)
B Antinuclear antibody assay (may classify the two major categories of arthritis into seronegative vs seropositive, but it certainly does not establish diagnosis)
C Rheumatoid factor assay (non-specific for Rheumatoid arthritis and will not establish a diagnosis.)
D Anti–cyclic citrullinated peptide antibody assay (will help in establishing the diagnosis of Rheumatoid, but the patients presentation is not consistent with rheumatoid).
E No additional studies ( these cheap nerds that makes make questions love to do nothing. "it is clinical diagnosis") I won't be surprised if that is the answer.
And thats the answer
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  #10  
Old 06-06-2011
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Interesting,
the take home message is that the people that make these exams are either Lazy or Cheap.
If a patient comes crushing down infront of them they would rather go ahead and smoke weed in their office.
I am joking, but "it is not going to change the outcome or the patient management". if you think about it the outcome is always death because if they don't die tomorrow, they will few years down the road.
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  #11  
Old 06-06-2011
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Quote:
Originally Posted by 99er View Post
Interesting,
the take home message is that the people that make these exams are either Lazy or Cheap.
If a patient comes crushing down infront of them they would rather go ahead and smoke weed in their office.
I am joking, but "it is not going to change the outcome or the patient management". if you think about it the outcome is always death because if they don't die tomorrow, they will few years down the road.

I realize and appreciate you're only joking, but I do think it's important that physicians acknowledge and are aware of the situations in which testing and interventions are not necessary.

For one, tests, interventions, and treatments are never without risks. Two, even without socialized medicine, we do not have infinite resources. Three, for those who are uninsured or have very high deductibles, unnecessary tests and intervention can be a huge detriment to family finances.
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  #12  
Old 06-06-2011
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Quote:
Originally Posted by 99er View Post
thanks,
my final answer = infected knee joint of a patient with history of osteoarthritis???
my next step would be: (Aspiration of the knee joint--> gram stain and culture, etc..) ESR, CBC with differential

I like ordering ESR which could also differentiate between the seronegative arthropathy vs ANA positive rheumatologic disease. Psoriatic arthritis also involves the DIP??
I thought about the osteoarthritis option as well, but the morning stiffness threw me off. if the knee was infected (previously damaged by the osteoarthritis) then patient would have had fever??
Her sister having the Lupus, makes me question autoimmune disease?

you know what they say, if anything looks weird, it could always be LUPUS.
Lupus arthritis is generally considered to be "non-deforming." While it does occur, it is far less common than in RA.
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  #13  
Old 06-22-2011
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thank you very much for the question..this was an interesting one!!!!
No additional studies do fit the bills in this question though given the clinical scenario and non-specificity of the options...
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