Q63) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. The most appropriate next step in management :
A. Start etanercept
B. Start Ibuprofen and follow-up in one month.
C. Start Ibuprofen and Methotrexate
D. Obtain plain x-rays of hands and wrists
E. Obtain anti-nuclear antibodies
b/c
c
d
d. first we have to look for erosion and xray changes . then treat
D, then C
Answer. D
The patient has the criteria for the diagnosis of Rheumatoid Arthritis. Once Rheumatoid arthritis is diagnosed, some baseline imaging study to evaluate the hands and the wrists must be performed. This will help to assess the severity of the disease at the time of initiation of therapy and also, for comparision with post treatment radiographs to evaluate response to the therapy . Plain radiographs of the hands and wrists are appropriate. Further managements depends upon the baseline severity of the disease at the time of diagnosis.
Mild RA : less than 6 inflamed joints, no extra-articular manifestations, no bony erosions or joint cartilage loss.
Moderate RA : Elevated ESR, Positive RA or positive Anti – CCP antibodies, radiographic changes such as osteopenia or small peripheral erosions and minimal joint space narrowing, no extra-articular disease.
Severe RA : imaging studies showing bony erosions and loss of cartilage, high titers of RF or Anti-CCP, presence of extra-articular manifestations, Anemia of chronic disease, Hypoalbuminemia.
Ans. A is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study.
Ans. B is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study. This option is appropriate if the patient is determined to have early, mild RA. Imaging must be performed to assess if this is mild or severe RA.
Ans. C is incorrect. It is inappropriate to start therapy with out asessing baseline bone disease with an imaging study. This option is correct if the patient is determined to have early, severe RA. Imaging must be performed to assess if this is mild or severe RA.
Ans. E is incorrect. The clinical criteria and positive anti-ccp suggest rheumatoid arthritis in this patient. There is no reason to obtain ANA.
D
thanks dr red .