A 46-year-old woman comes to the office due to pain in her hands and knees. The patient has had pain and stiffness in her hands over the past several months that causes difficulty gripping a coffee cup or holding a pen. Over the past 2 weeks, she has also had pain in her knees. The symptoms are worse in the mornings or after prolonged immobility but gradually improve with physical activity over an hour. The patient has no other medical conditions and takes no medications. She does not use tobacco, alcohol, or illicit drugs, and works as a paralegal. Vital signs are within normal limits. Physical examination shows mild swelling and tenderness of the small joints of the hands. There is a nontender nodule near the right elbow over the back of the forearm. Examination of the remainder of the joints is normal. Erythrocyte sedimentation rate is 45 mm/hr. This patient's current pathologic process is most likely to involve which of the following structures?

Question

A 46-year-old woman comes to the office due to pain in her hands and knees.  The patient has had pain and stiffness in her hands over the past several months that causes difficulty gripping a coffee cup or holding a pen.  Over the past 2 weeks, she has also had pain in her knees.  The symptoms are worse in the mornings or after prolonged immobility but gradually improve with physical activity over an hour.  The patient has no other medical conditions and takes no medications.  She does not use tobacco, alcohol, or illicit drugs, and works as a paralegal.  Vital signs are within normal limits.  Physical examination shows mild swelling and tenderness of the small joints of the hands.  There is a nontender nodule near the right elbow over the back of the forearm.  Examination of the remainder of the joints is normal.  Erythrocyte sedimentation rate is 45 mm/hr.  This patient's current pathologic process is most likely to involve which of the following structures?

Quizplus · Accepted Answer

11ec25c8_d520_1856_bc81_6f9351bd2845_MD0003_00 This patient has symmetric arthritis involving the hands, wrists, and knees, consistent with rheumatoid arthritis (RA), a systemic inflammatory disorder characterized by synovial inflammation and progressive joint damage. Typical joint findings in early RA include tenderness, restricted range of motion, and bogginess (soft tissue swelling and effusions). Common associated findings (seen in this patient) including morning stiffness, rheumatoid nodules (firm, nontender, subcutaneous nodules at pressure points such as the elbows or forearms), and elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein). Reduced grip strength is a frequent complaint in early disease. RA involves primarily the metacarpophalangeal and proximal interphalangeal joints of the fingers, metatarsophalangeal joints of the toes, and the wrist (carpometacarpal) joints. As the disease progresses, larger and more proximal joints (eg, knees, elbows, shoulders) may also be involved. However, the distal interphalangeal (DIP) joints are not involved. The axial skeleton is also usually spared, with the important exception of the cervical spine. RA involvement of the cervical spine can lead to atlantoaxial subluxation, an important and potentially life-threatening complication that can cause spinal cord compression and difficulties with intubation (eg, during anesthesia). Features of cervical myelopathy in RA include neck pain, progressive spastic quadriparesis, and sensory deficits in the hands and feet. atlantoaxial subluxation (Choice B) The costochondral joints are not lined by synovium and are not affected in RA. (Choice C) 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. (Choices D and E) The seronegative spondyloarthropathies (eg, ankylosing spondylitis, reactive arthritis, psoriatic arthritis) commonly involve the sacroiliac joints; they also often cause of inflammation at tendon insertion sites and ligament insertion sites (ie, enthesitis). Although psoriatic arthritis may also present as a symmetric polyarthritis similar to RA, the DIP joints are often involved, and most patients have skin lesions or nail pitting. Also, the rheumatoid nodule in this patient would not be seen in these disorders. Educational objective: Rheumatoid arthritis is characterized by synovial inflammation and progressive joint damage. It most commonly affects the peripheral joints, especially the metacarpophalangeal and proximal interphalangeal joints of the fingers, metatarsophalangeal joints of the toes, and the wrists. Involvement of the cervical spine can lead to atlantoaxial subluxation and spinal cord compression. References: Rheumatoid arthritis. (http://www.ncbi.nlm.nih.gov/pubmed/20870100) Rheumatoid arthritis of the cervical spine-clinical considerations. (http://www.ncbi.nlm.nih.gov/pubmed/22035393)

A 46-Year-Old Woman Comes to the Office Due to Pain