A 47 year old white man presented to the office with progressive pain and stiffness of hands and feet of five years duration. During this time he once experienced swelling of the knuckles of his right hand that resolved spontaneously within a week. Diclofenac 50 mg twice daily had not been effective. A year ago ankle osteoarthritis had been diagnosed arthroscopically. He did not smoke or drink alcohol. His father, who had diabetes, also had painful joints. On examination, he was noted to be tanned, with a body mass index of 27. He had subtle arthritis of the second and third metacarpophalangeal joint of the left hand and third metacarpophalangeal joint of the right hand, Heberden’s nodes of several distal interphalangeal hand joints, and crepitus of ankle and knee joints bilaterally. The liver was palpable 3 cm below the right costal margin. Otherwise, physical examination was unremarkable. Laboratory tests and radiographs were ordered.
CBC
RBC
WBC 6.4
Hct 54.3%
Hgb 16.9 g/dl
MCV 11
MCH
MCHC 38
Plt 34500/mm3
Chemistry
Na 135 meq/dL
K 3.5 meq/dL
Cl 101 meq/dL
CO2 25 meq/L
BUN 12mg/dL
Cr 0.6 mg/dL
Glu 90 mg/dL
Ca 8.5 mg/dL
Alk Phos 224 IU/dL
AST 107 IU/L
Alt 86 IU/L
GGT 33 IU/L
Hand X-Ray
- What abnormalities can be seen on the x-ray?
- What are the differential diagnoses for this patient’s joint problems?
- How is this clinical diagnosis confirmed?
Sample Solution