A 40-year-old woman comes to the office due to joint pains. The patient has had achy pain in her hands and feet for the past several months, which is worse in the morning. She says her fingers feel stiff when she wakes up and she has difficulty opening doors or holding spoons. The pain gradually improves over 2-3 hours, but the patient feels fatigued throughout the day. Taking ibuprofen provides some symptom relief. Medical history is otherwise unremarkable, and she takes no other medications. Vital signs are within normal limits. Physical examination shows no rashes or oral ulcers. The wrists and fingers are swollen bilaterally and are tender to palpation. Laboratory testing reveals that hematocrit is 33% and serum creatinine is normal. This patient's current condition is most likely to directly increase her risk for which of the following?

Question

A 40-year-old woman comes to the office due to joint pains.  The patient has had achy pain in her hands and feet for the past several months, which is worse in the morning.  She says her fingers feel stiff when she wakes up and she has difficulty opening doors or holding spoons.  The pain gradually improves over 2-3 hours, but the patient feels fatigued throughout the day.  Taking ibuprofen provides some symptom relief.  Medical history is otherwise unremarkable, and she takes no other medications.  Vital signs are within normal limits.  Physical examination shows no rashes or oral ulcers.  The wrists and fingers are swollen bilaterally and are tender to palpation.  Laboratory testing reveals that hematocrit is 33% and serum creatinine is normal.  This patient's current condition is most likely to directly increase her risk for which of the following?

Quizplus · Accepted Answer

11ec25c8_d51b_d293_bc81_a960c7c23f30_MD0003_00 This patient has a chronic symmetric polyarthritis consistent with rheumatoid arthritis (RA). RA is a progressive inflammatory disorder that is more common in women; it can occur at any age, although peak incidence is at age 30-60. RA is characteristically associated with prolonged morning stiffness, and symptoms may be more noticeable in the dominant hand. The most commonly affected joints include the metacarpophalangeal joints, metatarsophalangeal joints, proximal interphalangeal joints, wrists, and knees. Extraarticular manifestations are common in RA, especially in patients with positive serologies (eg, rheumatoid factor, cyclic citrullinated peptide antibodies). Systemic features (eg, weight loss, fatigue, anemia) are frequently present. Rheumatoid nodules (firm, nontender, subcutaneous nodules) may be seen at pressure points such as the elbows or forearms. Other complications include pleural effusions, fibrotic/restrictive lung disease, coronary atherosclerosis, and autoimmune exocrine dysfunction (ie, Sjögren syndrome). In addition, inflammatory cytokines (eg, tumor necrosis factor, interleukin-1) in RA can promote focal, periarticular, or diffuse (ie, osteopenia/osteoporosis) bone loss. Relative immobility and treatment with systemic glucocorticoids can also contribute. The risk of osteoporosis is approximately twice as high in patients with RA compared to the general population and carries an associated risk for fractures. Management should include regular exercise, optimization of vitamin D and calcium intake, minimization of glucocorticoid doses, and bisphosphonate therapy. (Choice A) Dermatomyositis can be seen as a paraneoplastic manifestation of multiple malignancies, especially adenocarcinoma of the breast, lung, and ovaries. There is a small increased risk of lymphoma in RA, but RA does not appear to have a major association with breast cancer, and some studies have found a slight decrease in risk. (Choice B) Esophageal dysmotility is a major manifestation of systemic sclerosis (scleroderma) but is not prominently associated with RA. (Choice D) Inflammatory bowel disease is associated with both axial spondyloarthritis and peripheral arthritis. The peripheral arthritis can manifest as a self-limited pauciarticular arthritis (typically affecting the knee) or a chronic polyarthritis that primarily affects the metacarpophalangeal joints. Although this second type may resemble RA, it is uncommon and almost always follows onset of gastrointestinal symptoms. (Choice E) The lumbar facet joints are commonly involved by osteoarthritis, and the lumbar spine is also a common site for disc herniation and spinal stenosis. However, RA does not typically involve the thoracic, lumbar, or sacral spine. Educational objective: Patients with rheumatoid arthritis are at increased risk of developing osteopenia, osteoporosis, and bone fractures. Management includes adequate physical activity, optimization of calcium and vitamin D intake, minimization of glucocorticoid therapy, and bisphosphonate treatment. References: Management of osteoporosis in rheumatoid arthritis patients. (http://www.ncbi.nlm.nih.gov/pubmed/25626121)

A 40-Year-Old Woman Comes to the Office Due to Joint