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NYU Medicine Grand Rounds Clinical Vignette

NYU Medicine Grand Rounds Clinical Vignette. Julia Manasson, PGY2 November 20 th , 2013. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medicine Grand Rounds Clinical Vignette

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  1. NYU Medicine Grand Rounds Clinical Vignette Julia Manasson, PGY2 November 20th, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 27 year old woman presents with pain and stiffness in both wrists for four months.

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Two years prior to current presentation the patient developed diffuse joint pain. An auto-immune work-up was performed, which was reportedly unremarkable. • Her symptoms fluctuated until four months prior to presentation when the patient developed joint pain and stiffness, most notably in the wrists bilaterally. She was seen by a hand surgeon and underwent an MRI which was only significant for ganglion cysts. • On presentation, she reported bilateral knee pain, left greater than right. She also reported left hand pain and diffuse swelling of the proximal interphalangeal joints, particularly the 3rd digit. • She described the pain as constant, unrelated to activity, and minimally responsive to non-steroidals.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Inverse psoriasis: diagnosed at age 12, treated with topical medications (tacrolimus and steroids) • Past Surgical History: • Denies • Social History: • Denies tobacco and illicit drug use. Drinks alcohol on occasion, on average 1 drink/week. • Family History: • Father with psoriasis • Allergies: • No Known Drug Allergies • Medications: • Betamethasone 0.12% foam, apply topically twice daily • Tacrolimus 0.1% ointment, apply topically twice daily • Sertraline 150 mg by mouth daily • Methylphenidate 20 mg by mouth every morning • Birth control 1 tablet daily

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: well appearing, no acute distress • Vital Signs: T: afebrile, BP: 110/55, HR: 72 • Skin: Plaques over buttocks and intergluteal crease. • MSK: Diffuse tenderness to palpation of proximal interphalangeal joints. The left 3rd interphalangeal joint notable for swelling and synovitis. • Remainder of physical exam unremarkable.

  6. Dactylitis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS http://www.cdaarthritis.com/images_slides/images_slides_43.htm

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: WBC 8.5, Hb 12.2, Plt 214 • BMP: Unremarkable, BUN 10, Cr 0.67 • Hepatic panel: Unremarkable • Erythrocyte sedimentation rate: 23 • C-reactive protein: 4.3 • Rheumatoid factor: 4.6 • Anti-cyclic citrullinated peptide IgG/IgA: 5 • HLA: A*29:KBF • Quantiferon: Negative • Hepatitis B: Immune • Hepatitis C: Negative

  8. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Bilateral hand/wrist x-ray: • No acute fracture or dislocation. • Joint spaces and alignment are maintained. • Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. • Soft tissues are otherwise unremarkable. • Bilateral foot x-ray: • -Unremarkable

  9. Hand X-ray UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Lateral PA

  10. Wrist XR UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Lateral AP

  11. Foot XR UNITED STATES DEPARTMENT OF VETERANS AFFAIRS R Lateral AP L Lateral

  12. XR Descriptions UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Bilateral hand/wrist XR: • No acute fracture or dislocation. • Joint spaces and alignment are maintained. • Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. • Soft tissues are otherwise unremarkable. • Bilateral foot XR: • - Unremarkable

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Diagnosis • Given the patient’s prior history of psoriasis, new complaints of joint stiffness and pain, physical exam, and imaging studies, the patient was diagnosed with psoriatic arthritis.

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Treatment • Patient was started on Methotrexate 10 mg weekly and Folic acid 1 mg daily. Plan was to uptitrate the dose of Methotrexate as tolerated while monitoring labs. • If no response within 3 months, the patient would need to be started on a TNF inhibitor.

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