Ace the Case: A 55-Year-Old Woman With Bilateral Hand Pain

Case Presentation

Chief Complaint: 1-month history of bilateral hand pain

History of Present Illness: A 55-year-old woman presents to the rheumatology office for evaluation of bilateral hand pain. The pain started about 1 month earlier and she notes subjective swelling of the joints in her hands. She admits to morning stiffness lasting approximately 20 minutes and then improving. She works as a hairdresser and the pain in her hands has made it difficult to work. She has not taken any medications for the pain. She did an Internet search about joint pain and is concerned that she has rheumatoid arthritis. 

Past Medical History: Irritable bowel syndrome; gastrointestinal bleed; family history of ulcerative colitis in her mother

Physical Examination: Blood pressure: 128/88 mm Hg, bilaterally, afebrile; pulse: 72 beats per minute; O2 is 100% on room air. Bony swelling of multiple distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints bilaterally, which are tender to palpation. No acute synovitis noted. Remainder of examination is normal.

Labs: Rheumatoid factor: 35 IU/mL; erythrocyte sedimentation rate: 32 mm/hr; anticyclic citrullinated peptide: negative

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What is the patient’s most likely diagnosis?
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Correct Answer: B. 

Rationale: This patient most likely has a diagnosis of osteoarthritis (OA) of the hands. Osteoarthritis can affect the DIP joints and the PIP joints of the hand classically, with sparing of the metacarpophalangeal joints. Osteoarthritis involvement of the first carpometacarpal joint can be particularly problematic and can lead to significant pain, limitations in functionality, and reduced grip strength.1 The nodular swelling over the DIPs and PIPs are termed heberden and bouchard nodes, respectively. As opposed to inflammatory arthritides such as rheumatoid arthritis, psoriatic arthritis, and inflammatory bowel disease associated arthritis, which cause prolonged morning stiffness (>1 hour), patients with OA typically have morning stiffness that lasts 30 minutes or less.1 In addition, patients who do a lot of physical work with their hands may be predisposed to developing OA.