A 62-year-old woman comes to the office due to activity-related joint pain in the hands and periodic morning stiffness that lasts 10-15 minutes. The pain is moderately severe and has begun to limit her activities. The patient has attempted to treat the pain with acetaminophen, which provided only partial relief. Past medical history is notable for hypertension and diabetes mellitus. Physical examination shows firm nodules over the distal interphalangeal joints bilaterally as shown in the image below. Which of the following is the most likely cause of this patient's symptoms?

Question

A 62-year-old woman comes to the office due to activity-related joint pain in the hands and periodic morning stiffness that lasts 10-15 minutes.  The pain is moderately severe and has begun to limit her activities.  The patient has attempted to treat the pain with acetaminophen, which provided only partial relief.  Past medical history is notable for hypertension and diabetes mellitus.  Physical examination shows firm nodules over the distal interphalangeal joints bilaterally as shown in the image below.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3a5e_69a8_9249_2d6a1c179878_MD0001_00 This patient, an older woman with use-dependent joint pain, has typical features of osteoarthritis (OA). Patients with OA of the hands may also have osteophyte formation leading to bony enlargement of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints (Heberden and Bouchard nodes, respectively). OA also commonly involves the spine and the large weight-bearing joints of the lower extremities (knees, hips). Morning stiffness is more typical of the inflammatory arthritides such as rheumatoid arthritis (RA), but may be experienced for a short duration (<30 minutes) in patients with OA as well. In contrast, morning stiffness in RA may persist for hours and is often accompanied by systemic symptoms (eg, fever, weight loss). RA typically causes symmetric arthritis of the metacarpophalangeal, PIP, and other joints, but DIP joint involvement is less common (Choice F). In contrast to the bony enlargement in OA, the involved joints in RA have active synovitis, with warmth and spongy swelling. (Choice A) Fibromyalgia is characterized by diffuse musculoskeletal pain that worsens with weather changes, psychological stress, or reduced sleep. It does not cause joint deformities. (Choice B) Gout causes acute, episodic inflammatory monoarthritis that is characterized by a red, swollen, and painful joint. It usually affects the first metatarsophalangeal joint, knees, or ankles. (Choice C) Septic arthritis causes intense pain, swelling, and redness of affected joints. The knee, hip, and shoulder are most commonly involved. The finger joints are less often affected and bony joint enlargement is not typical. Moreover, systemic signs, including fever, chills, and malaise, may be present. (Choice E) Reactive arthritis is characterized by urethritis, conjunctivitis/uveitis, and arthritis (mainly of the knees, ankles, and feet) and is most common in young men. Hand joint involvement is not typical. Educational objective: Osteoarthritis of the hands is characterized by osteophyte formation leading to hard bony enlargement of the distal interphalangeal joints (Heberden nodes) and proximal interphalangeal joints (Bouchard nodes). Brief morning stiffness may be present. __________ References: EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. (http://www.ncbi.nlm.nih.gov/pubmed/18250111)

A 62-Year-Old Woman Comes to the Office Due to Activity-Related