Clinical Correlations The NYU Langone Online Journal of Medicine

1. Clinical Correlations The NYU Langone Online Journal of Medicine http://clinicalcorrelations.org

2. NYU Medicine Grand Rounds Clinical Vignette Matthew Lee, MD PGY-2 3/12/14 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

3. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient is a 69 year-old woman who returned to Rheumatology clinic with worsening bilateral knee pain for the past year.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Since 2004, the patient has had bilateral knee pain and stiffness • Over 3 years, the patient described progressive worsening of the above symptoms • She was followed by her primary care physician who initially prescribed NSAIDs and physical therapy.

5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Despite the prescribed therapies, her symptoms progressed to become physically limiting. • In 2009, she was referred for Rheumatology consultation • Her initial x-rays were notable for advanced bilateral medial joint space narrowing, varus deformity, and large osteophytes consistent with osteoarthritis.

6. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Because of her symptoms and imaging, surgery was discussed, however the patient declined. • In addition to NSAIDs and physical therapy, she received intra-articular steroids and viscosupplementation with hylan G-F 20 injections in 2011-2012. • Due to worsening symptoms, she underwent a series of hyaluronic acid injections that finished in 12/2012.

7. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Despite the hyaluronic acid injections, she noticed minimal relief and continued to have severe knee pain over the past year before returning to Rheumatology clinic this January.

8. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History/Past Surgical History • Thyroid cancer with thyroidectomy and radiation therapy in 2007 • Obesity • Osteoarthritis of bilateral knees • Osteoporosis with history of wrist fracture (2009) • Allergies: • No Known Drug Allergies • Medications: • Ibuprofen as needed • Levothyroxine 112 mcg by mouth daily

9. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Family History: • Mother had osteoporosis and history of a hip fracture • Social History: • Remote history of tobacco use (quit over 25 years ago) • Social alcohol use • Retired nurse; now working as real estate agent

10. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Vital signs were unremarkable, however BMI was stable at 30 kg/m2. General: Well-appearing woman with a noticeable antalgic gait bilaterally. Knees: bilateral crepitus and mild swelling; no warmth. Pain elicited near full flexion Hands: Heberden’s nodes in multiple distal interphalangeal joints of bilateral hands Remainder of exam was normal

11. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Synovial Fluid Results • Appearance: clear, yellow • Cell Count: 312 nucleated cells (48% lymphocytes, 39% macrophages, 0% polys) • No crystals • Negative bacterial culture

12. Imaging UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

13. Imaging UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

14. Imaging UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Diagnosis and Treatment Plan Diagnosis: progressive tricompartmental osteoarthritis • Intra-articular injection of methylprednisolone • Physical Therapy • Weight loss encouragement • Consideration of total knee arthroplasty