NYU Medical Grand Rounds Clinical Vignette

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NYU Medical Grand Rounds Clinical Vignette

• Carolina Cabral MD, PGY-2
• November 11, 2009

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Chief Complaint
A 61-year-old man presented complaining of
widespread joint swelling and pain for 2 months.
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History of Present Illness

• The patient was in his usual state of health
  until 2 months prior to presentation, when he
  reported the onset of progressive joint pain at
  the knees, wrists, metacarpophalangeal (MCP) and
  proximal interphalangeal (PIP) joints.
• His pain had not been relieved by naproxen or
  acetaminophen with codeine.

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Additional History

• Past Medical History
• Hypertension
• Hyperlipidemia
• Past Surgical History
• None

• Family History
• Non-contributory
• Social History
• Married with children
• Road construction supervisor
• Eighth grade education
• Denies alcohol use
• Denies illicit drug use
• Denies smoking

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Outpatient Medications
Naproxen 880mg every 6 hours Acetaminophen with
codeine 325/30mg three times daily
Allergies No known drug allergies
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Physical Examination
General Well-appearing man in no apparent
distress
Vital Signs T 98.5 F, BP 130/80, HR 70, RR 12
Musculoskeletal Swelling and tenderness of all
MCP and PIP joints, wrists and knees
The remainder of the physical exam was normal.
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Laboratory Findings

• CBC within normal limits

• Basic metabolic panel within normal limits

• Hepatic Panel within normal limits

• ESR 43 mm/hr (normal lt 10 mm/hr)

• CRP 30 mg/dL (normal lt 10 mg/dL)

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Additional Studies

• X-ray studies of affected joints
• No joint space erosions or narrowing

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Working Diagnosis
Rheumatoid arthritis
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Other studies

• As a part of a routine clinical assessment, the
  patient completed a baseline self-report using
  the multidimensional health assessment
  questionnaire (MDHAQ) . His scores were
• Physical function (FN) 2.7 (scale 0-10)
• Pain (PN) 9.6 (scale 0-10)
• Global status (PTGL) 8.9 (scale 0-10)
• RAPID3 (Routine assessment of patient index
  data) 21.2 (scale 0-30)
• RAPID3 is an index of FN, PN, PTGL, classified
  for severity.
• A score of gt12 is classified as high severity.

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MDHAQ/RAPID304 Nov 2003 3 RA Core Data Set
scores FN (010) 2.7 PN (010) 9.5 PTGL
(010) 9.0 RAPID3 (030) 21.2 Severity 12.1
-30 High 6.1-12Moderate 3.1-6Low 0-3Near
remission
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Treatment Course

• Due to his significant joint swelling,
  functional disability and pain, the patient was
  treated with prednisone 3 mg a day, methotrexate
  10 mg per week, and folic acid 1mg/day.

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Visit 1 4 Nov 2003
Nnew drug, Cchange in dose, Ttaper,
D/Cdiscontinue
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Treatment Course

• The patient returned 2 months later without
  symptoms.
• His scores for function and pain were
  significantly improved.
• His ESR had fallen from 43 to 8 and CRP from 30
  to 3.
• He reported no problems with medications.

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MDHAQ/RAPID313 Jan 2004 3 RA Core Data Set
scores FN (010) 0 PN (010) 0.5 PTGL
(010) 0.5 RAPID3 (030) 1.0 Severity 12.1-
30 High 6.1-12Moderate 3.1-6Low 0-3Near
remission
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Visit 2 13 Jan 2004
N new drug, C change in dose, T taper, D/C
discontinue
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Treatment Course

• The patient remained stable over the next 8
  months in near-remission status.
• After this time, he presented with recurrent
  swelling and tenderness of all of his MCP and PIP
  joints.
• His ESR and CRP were normal.
• His assessments by MDHAQ and RAPID3 were
  significantly worse.

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• MDHAQ/RAPID328 Dec 2004
• 3 RA Core Data Set scores
• FN (010) 0
• PN (010) 6.0
• PTGL (010) 5.5
• RAPID3 (030) 11.5
• Severity
• 12.1-30 High
• 6.1-12Moderate
• 3.1-6Low
• 0-3Near remission

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6.0
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11.5
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Visit 5 28 Dec 2004
Nnew drug, Cchange in dose, Ttaper,
D/Cdiscontinue
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Treatment Course

• In an extensive discussion of treatment options,
  the patient indicated that he wanted to return to
  his physically demanding work as soon as
  possible.
• His methotrexate was raised from 15 to 25 mg per
  week.
• Adalimumab was added, 40 mg every other week.
• Patient had a good response, to near-remission
  status at a visit 2 months later.

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• MDHAQ/RAPID38 Feb 2005
• 3 RA Core Data Set scores
• FN (010) 0
• PN (010) 0.0
• PTGL (010) 0.5
• RAPID3 (030) 0.5
• Severity
• 12.1-30 High
• 6.1-12Moderate
• 3.1-6Low
• 0-3Near remission

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Visit 6 8 Feb 2005
Nnew drug, Cchange in dose, Ttaper,
D/Cdiscontinue
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Final Diagnoses
Rheumatoid Arthritis, currently in near-remission
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