A 68-year-old woman comes to the office due to a 4-year history of pain and stiffness in the fingers of both hands. The pain is worse after she does housework and improves with rest. She also has morning stiffness lasting 10-15 minutes after awakening. The patient has no other joint pains, weight loss, rash, or shortness of breath. Medical history is notable for type 2 diabetes mellitus and Graves disease treated with radioiodine therapy. She smoked cigarettes for 10 years and quit at age 40. Vital signs are normal. The image below shows examination findings in the hands, and the remainder of the physical examination is normal. Which of the following is the most appropriate next step in management?

Question

A 68-year-old woman comes to the office due to a 4-year history of pain and stiffness in the fingers of both hands.  The pain is worse after she does housework and improves with rest.  She also has morning stiffness lasting 10-15 minutes after awakening.  The patient has no other joint pains, weight loss, rash, or shortness of breath.  Medical history is notable for type 2 diabetes mellitus and Graves disease treated with radioiodine therapy.  She smoked cigarettes for 10 years and quit at age 40.  Vital signs are normal.  The image below shows examination findings in the hands, and the remainder of the physical examination is normal.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d11d_f0d6_bc81_4d2993ad9504_MD0003_00 This patient has osteoarthritis (OA) of the hands, which presents with chronic joint pain that is worse with activity and relieved with rest. Examination shows Heberden and Bouchard nodes at the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints, respectively, which represent bony enlargement adjacent to the articular cartilage and are pathognomonic for OA. Bony hypertrophy is often also found at the first carpometacarpal joint (base of thumb). OA of the hands is primarily a clinical diagnosis and is often apparent at the time of initial presentation. X-ray may be performed in ambiguous cases and may show decreased joint space, subchondral sclerosis, and periarticular osteophytes. However, imaging is less sensitive than examination findings and is usually unnecessary for diagnosis or management (Choice F). This patient has classic examination findings, there are no additional diagnostic considerations, and imaging does not change how the OA is treated. Therefore, no additional testing is needed. periarticular osteophytes (Choice A) Antinuclear antibody (ANA) is used to screen for systemic lupus erythematosus (SLE). However, SLE arthritis is typically migratory and nondeforming, and patients usually have manifestations in multiple domains (eg, skin, kidneys, lungs); ANA has low specificity (many false positives) and should not be used in patients without a high pretest probability of SLE. (Choice B) Chest x-ray is indicated for evaluating hypertrophic osteoarthropathy, which is commonly associated with adenocarcinoma of the lung and other pulmonary diseases (eg, bronchiectasis). However, this condition presents subacutely with digital clubbing, periostosis of long bones, and synovial effusions. This patient has DIP and PIP joint enlargement, which is classic for OA. digital clubbing (Choice D) Rheumatoid arthritis often affects the hands but typically presents with boggy synovitis and deformity at the metacarpophalangeal joints and wrists; DIP joint involvement is uncommon. Patients typically experience prolonged (>1 hr) morning stiffness; brief (<30 min) stiffness is more characteristic of OA. metacarpophalangeal joints (Choice E) Tophi are subcutaneous nodules composed of urate crystals in patients with gout. They often occur in the hands but are typically isolated or irregular and asymmetric, not uniform across the DIP and PIP joints, as with Heberden and Bouchard nodes. subcutaneous nodules Educational objective: Heberden and Bouchard nodes represent bony enlargement at the distal and proximal interphalangeal joints and are pathognomonic for osteoarthritis. Osteoarthritis of the hands is primarily a clinical diagnosis; imaging (eg, x-ray) is less sensitive than examination findings and is usually unnecessary for diagnosis or management.

A 68-Year-Old Woman Comes to the Office Due to a 4-Year