Clinical Vignette XII

• Which of the following is the least appropriate next step in management of this patient?

A 42-year-old African American male is evaluated in the Medtigo Medical Clinic for a 3-month history of progressively worsening joint pain, swelling, and morning stiffness in both of his hands, wrists, knees, and feet. When he first noticed the symptoms several months ago, they were minor and only involved his knees and feet. He initially thought the minor joint pain, swelling, morning stiffness, and general muscle soreness would eventually resolve in a few weeks once his body acclimated to a new total physique cross-training exercise program which he had just started at the time in an effort to lose weight. After a month of starting the new exercise program, his generalized muscle soreness improved significantly but his joint pain, swelling, and morning stiffness seemed to only worsen. Over the next two months, he also noticed the development of similar symptoms in the joints of both hands and wrists which started as minor joint pain, swelling, and morning stiffness but slowly worsened in a manner not much different than his initial joint problems involving his knees and feet. The patient’s multi-joint pain and swelling worsened to the point where he could no longer participate in the total body cross-training exercise program he had started three months ago. He states “,my joint pains would actually improve during the light warm-up sessions at the beginning of each class but when the fitness instructor increased the intensity level of the exercises, the pain in my joints just became too unbearable for me to continue and I would have to sit out the rest of the class.” He then states, “I had to quit attending the exercise training program because the pain and swelling in my joints severely limited how much exercise I could perform especially at the intensity level expected by the fitness instructor.”

Presently, his multi-joint pain, swelling, and morning stiffness moderately limits some range of motion when performing certain movements involving his hands, wrists, knees, and feet. The patient reports the morning stiffness in his joints can last from 30 minutes up to two hours or more upon waking every day but seems to mildly improve once he moves around to get ready for work. He also reports some mildly noticeable improvement in his multi-joint pain once he moves around his apartment preparing for work every day. Despite this noticeable mild improvement in his multi-joint pain and morning stiffness, the patient readily admits the pain is constantly present at varying levels as well as the swelling in the involved joints. He often takes naproxen which provides some temporary and very mild pain relief. His medical history is notable for hypertension, dyslipidemia, gastroesophageal reflux disease, and generalized anxiety disorder. His current medications are benazepril, chlorthalidone, esomeprazole, rosuvastatin, fluoxetine, and over-the-counter naproxen as needed. To his knowledge, he has no known allergies. He is currently sexually active with his girlfriend of three years and admits to not always using protection. He does not consume alcohol, smoke cigarettes, chew tobacco, or use recreational drugs. He has an older sister who was diagnosed with systemic lupus erythematosus about ten years ago. His mother has Hashimoto’s thyroiditis and osteoarthritis. His father has Type 1 diabetes, coronary artery disease with two bare metal stents, hypertension, and gout.

On physical examination, vital signs are normal. His body mass index is 26.5 kg/m². Palpation reveals bilateral swelling and tenderness in the third, fourth, and fifth proximal interphalangeal joints as well as the second, third, and fourth metacarpophalangeal joints of his hands, both wrists, both knees, and bilateral second, third, fourth, and fifth metatarsophalangeal joints of his feet. Cardiac exam reveals a normal S1 and S2 with a grade 1/6 mitral regurgitation murmur. Lung exam is clear to auscultation. There is a painless, small, rounded cyst measuring approximately 2.5 cm in diameter located on the inferomedial aspect of the right popliteal region. The remainder of the physical examination is unremarkable.

Given the patient’s history of present illness, signs and symptoms, clinical exam findings, medical history, family history, and laboratory testing results performed thus far, which of the following is the most likely diagnosis?

• The results from the appropriate laboratory tests reveal the following:

• Which of the following is the most appropriate next step in management of this patient’s newly diagnosed medical condition?

In addition to the laboratory tests and imaging study performed, which of the following is also considered part of the most appropriate next step in management of this patient’s newly diagnosed medical condition?

• The results of the most appropriate management steps reveal the following:

PA/Lateral view CXR:  normal 

Now that the patient’s diagnosis has been firmly established and the initial laboratory testing and imaging results have been completed without any clearly evident contraindications, first-line treatment will be initiated with metrotrexate and limited duration low-dose prednisone with follow-up appointment in two months. Which of the following vitamins should also be initiated as a supplement with this particular treatment regimen? 

• The results of the laboratory screening tests are as follows:

Which of the following biochemical mechanisms of action most accurately explains the supplemental use of folic acid with this patient’s initial treatment regimen for seronegative rheumatoid arthritis?

Based on the established diagnosis, current treatment regimen, and the newly obtained lab values, which of the following is the most appropriate next step in management of this patient?

• Two months later, the patient returns to the Medtigo Medical Clinical for a scheduled follow-up appointment to evaluate his overall symptomatic response to the initial treatment regimen, discuss any concerns or side effects he may be experiencing, and to review new blood work obtained earlier the same day. The patient reports an overall improvement in his multi-joint pain, swelling, and morning stiffness. He also reports being able to exercise again at moderate intensity for a prolonged period of time of up to 45 minutes without any significant joint pain. Furthermore, he states his range of motion in the involved joints has steadily improved over the past two months. When questioned about any side effects, the patient reports the initial treatment regimen sometimes gives him diarrhea, often makes him feel nauseated, and for the past two weeks he feels like he becomes more easily fatigued with moderately sustained exercise. Despite the mentioned adverse effects, the patient reports feeling significantly much better compared to the several months prior to initiating treatment. Further questioning reveals the patient has been compliant with his treatment regimen. He denies consuming any alcohol due to the potential side effects of the treatment regimen. He has been able to exercise on a regular basis again but at a mild-to-moderate level of intensity. He has been eating healthy with a slightly negative total daily caloric intake relative to his estimated basal metabolic rate. He no longer has to take any naproxen or any other over-the-counter NSAID for joint pain and swelling.

  On physical examination, vital signs are normal. His body mass index is 8 kg/m². Palpation reveals significantly decreased swelling and tenderness in the third through fifth proximal interphalangeal joints as well as the second through four metacarpophalangeal joints of his hands, both wrists, both knees and bilateral second through fifth metatarsophalangeal joints of his feet. Cardiac exam reveals a normal S1 and S2 with a grade 1/6 mitral regurgitation murmur. Lung exam is clear to auscultation bilaterally. The small, non-tender to palpation, rounded cyst measuring 2.5 cm in diameter located on the inferomedial aspect of the his right popliteal region appears unchanged. The remainder of the physical examination is unremarkable. The results of the patient’s new blood work obtain earlier today reveal the following:

• Prior to starting sulfasalazine as part of this patient’s treatment regimen, which of the following is the most appropriate next step in management?