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Test Your Knowledge #1-What is causing this patient's knee pain? by Alan Matsumoto, M.D. |
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A 66 year old woman with a 20 year history of rheumatoid arthritis comes to your office for a new patient consultation complaining of swelling and pain in her left knee. She was diagnosed with rheumatoid arthritis when she was 45 years old, when she presented with swelling and pain in multiple joints including her elbows, wrists, hands, knees, ankles and feet. She recalls being treated with a variety of non-steroidal medications (NSAIDs) and low dose prednisone. She initially was started on hydroxychloroquine and then intramuscular gold therapy. She did well on gold, eventually stopping therapy after 8 years. Her rheumatologist told her she was "in remission" and stopped seeing her. She has been treated with NSAIDs alone for the past 7 years.
Her current knee problems began about 8 months ago. Over the past several months she has had 4 to 5 episodes of severe swelling and pain in her left knee. Each episode lasts from 5 to 6 days before improving. She has morning stiffness lasting 15 minutes daily, mainly in her hands. She is currently only taking Ibuprofen 800 mg 4 times daily. On exam she has chronic deformities at the wrists, MCP and PIP joints, with chronic synovial thickening. Her left knee has good range of motion with crepitus but no demonstrable swelling, warmth or tenderness. Her right knee exam is similar to her left. Her shoulders have good active range of motion. Her feet show cock-up deformities at the MTP joints. Her main concern is that her rheumatoid arthritis has become active and is anxious to begin therapy if this is the case. She has heard about the new medications for rheumatoid arthritis and wants to try one.
A good next test might be: d. Lyme titer f. knee x-rays |
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