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Hand Pain



Hey whats going on guys? Today, were going to talk about a patient that came in with hand pain and a little bit about how were going to work this patient up and why we did the work up we did.  Alright guys, so first of all, I have this 30 year old female that came in and her main complaint was that she had bilateral hand pain right. So this is very important.  Its very important to differentiate between hand pain thats unilateral or bilateral.  Especially if she’s talking about joint pain because you have poly articular joint pain, you have mono articular joint pain, and its also very important to find out if this is going to be symmetric joint pain.  So she was complaining of bilateral hand pain but more so localized in the joints, and per her history she was having symmetrical bilateral joint pain.  She was also complaining of stiffness, now, she didn’t voluntarily bring this information up.  This is something that I had to ask.  Whenever someone comes in with bilateral joint pain, theres only one thing that should pop in to your mind or the first thing that should pop into your mind right away: rule out rheumatoid arthritis.  Especially, in a 30 year old female.  So what you want to do is ask these patients if they have trouble moving their hands, especially upon awakening.  So, a lot of these patients are going to have morning stiffness early in the course of their disease.  She says its been occurring for about 4 months now, and in the past 4 months, the pain has been gradually worsening.

Alright, so, we have to go over a good history.  According to her she denies any medical problems.  The only thing she is taking is aleeve for her joint pain.  The aleeve actually gets rid of her joint pain.  She denies any allergies and she denies having any history of prior surgery, which is also very important to know.  So, this doesn’t help us one way or the other.  Like I said, she has bilateral joint pain, she has morning stiffness, and we really want to rule out rheumatoid arthritis.

I ordered a CBC, I ordered an ESR, rheumatoid factor and something called anti-ccp.  Now, rheumatoid factor and anti-ccp are usually the lab work thats ordered to diagnose rheumatoid arthritis.  You also need to have an elevated ESR. Now rheumatoid factor is sensitive but not very specific.  So, were going to have patients with rheumatoid factor and the rheumatoid factor is about 70% sensitive but its not very specific.  So you can see rheumatoid factor in patients who also have lupus or other things of that nature.  Anti ccp has about the same sensitivity, about 70-80%, but the specificity is a lot higher at about 95%.  So its very important that if you want to rule out rheumatoid arthritis or are thinking about rheumatoid arthritis, your going to order both of these lab tests to confirm the diagnosis.  So, what were her results here?

She has a normal CBC, which didn’t help us.  She has an increased ESR, so that further points us to the diagnosis of rheumatoid arthritis.  She has a normal rheumatoid factor.  Like I said, a rheumatoid factor is somewhat sensitive, but not very specific. We had a positive anti ccp.  And an anti ccp should always be ordered in patients suspected of having rheumatoid arthritis, especially if they have a normal rheumatoid factor.  So, lets recap: she has a positive history of bilateral symmetric joint pain and she has the positive lab values.  She is diagnosed with rheumatoid arthritis.

Some clinical pearls that might differentiate this from what your going to see in board review or board exams type of things.  Classically your taught that rheumatoid arthritis does not affect the DIP joints, but in clinical practice they can.  They can definitely affect the DIP joints, but this happens later on in the disease.  This is not something thats going to happen immediately upon diagnosis or upon early manifestations.  The axial skeleton.  Rheumatoid arthritis will affect the joints, however, it will almost always spare the axial skeleton.  The only exception is going to be the cervical spine.  Patients with rheumatoid  arthritis will commonly complain of neck pain or neck stiffness and they can have cervical subluxation, which is something thats very important to know, especially in a trauma patient or somebody undergoing surgery.   This is because you don’t want to have that cervical spine sublux.  All patients need to be started on DMARDs.  It used to be thought that only certain patients need to be on DMARDs, such as those with moderate to severe disease.  It was also thought that mild disease can be treated with NSAIDs and prednisone for acute flares.  But, all patients need to be on DMARDs.  This is a progressive disease and is something that will worsen.  The only way to stop this is to initiate DMARDs.  The medication that I use most commonly is methotrexate.  With methotrexate, you do need to do some lab work and you need to be diligent about the lab work because it does have adverse effects, however, its probably one of the best medications out there for rheumatoid arthritis.  So, I start all patients on methotrexate, and the good thing about methotrexate is you can dose it once or twice weekly which is a little bit easier than doing something that is done daily.  Alright guys so this has been a quick case on rheumatoid arthritis.  Hope you guys learned something.  Hope you can take something to your clinical practice.  I appreciate it and you guys and I will see you guys on the next video!