A 51-Year-Old With Musculoskeletal Symptoms

AFFILIATIONS:
¹Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
²Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

CITATION:
Rubin RN. A 51-year-old with musculoskeletal symptoms. Consultant. 2022;62(7):e32-e34. doi:10.25270/con.2022.07.000020

DISCLOSURES:
The author reports no relevant financial relationships.

CORRESPONDENCE:
Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

A 51-year-old woman presents to your office with musculoskeletal symptoms that she had initially thought were exercise-related. The symptoms had started in the summer months but now have persisted for more than 6 months despite the usual attempts of relief using rest and nonsteroidal anti-inflammatory drugs (NSAIDs). The dominant symptoms are in her hands where she notes pain in multiple joints in both wrists, thumb, the metacarpophalangeal joint, and the proximal interphalangeal joint.

The patient reported times when redness and swelling in these areas were visible. She additionally notes a distinct stiffness and heaviness in the hands in the morning, which improves after several hours. These symptoms have markedly interfered with aspects of her life, such as athletic hobbies and work where she has trouble using her computer keyboard.

History. Her health is otherwise good overall. She has had a degree of glucose intolerance; her random blood glucose levels range from 110 to 125 mg/dL with normal hemoglobin A1C. She does not have any major medical diagnoses. She is slightly overweight and does not smoke or misuse alcohol. She currently works as a bank teller.

Physical examination. She is a healthy-appearing woman with a blood pressure of 115/75 mm Hg, a pulse rate of 88 beats/min, and a BMI of 26 kg/m². Results of a head, ears, eyes, nose, oral, and throat examination are unremarkable. No enlarged lymph nodes are noted, and a chest/cardiac examination is also unremarkable. No skin rashes are noted. A neurologic examination revealed no abnormalities or lateralizing signs.

A musculoskeletal examination revealed normal overall muscle mass. There is tenderness to palpation and forced motion in both wrists, both metacarpal-phalangeal joints of the thumbs, and the medial 2 metacarpophalangeal joints of the fingers of both hands. The aforementioned thumb joints are red and swollen as well. There is joint swelling and rubor in several proximal interphalangeal joints as well.

Laboratory testing. Results of a complete blood cell count show mild normocytic anemia with a red blood cell count of 11 g/dL and an elevated random blood glucose level of 125 mg/dL. All other results from biochemistry and metabolic panels were within normal limits. Her erythrocyte sedimentation rate was 69 mm/hr. Radiographic evaluation of the hands and feet was pending.

Which of the following is the optimal initial therapy for the presented patient?

A. Initiate an aggressive course of acetaminophen plus NSAIDs for at least 12 weeks before escalating therapy.
B. Consult a hand surgeon for carpal tunnel surgery.
C. Initiate a course of corticosteroids plus methotrexate.
D. Initiate a course of corticosteroids plus chloroquine.
E. Initiate a biologic disease-modifying antirheumatic drug.

Answer and discussion on next page.