From the Research
The appropriate workup for an 80-year-old man with morning unilateral painless hand swelling that improves throughout the day should begin with a thorough history and physical examination, focusing on inflammatory arthritis, particularly rheumatoid arthritis or polymyalgia rheumatica, given the patient's age. This presentation suggests remitting morning stiffness, which is characteristic of inflammatory arthritis. Initial laboratory tests should include complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibodies, as suggested by the most recent and highest quality study available 1. Uric acid levels should be checked to rule out gout, though the painless nature makes this less likely. Imaging studies should include plain radiographs of both hands to assess for joint space narrowing, erosions, or soft tissue swelling. If initial findings are inconclusive, ultrasound or MRI of the affected hand may provide better visualization of synovitis, tenosynovitis, or subtle erosions, with ultrasound being a reliable and cost-effective option for early diagnosis of rheumatoid arthritis 2. Additional considerations include evaluation for carpal tunnel syndrome, which can cause morning symptoms that improve with activity, and assessment of cardiac function since heart failure can cause dependent edema that improves with position change throughout the day. The patient should be referred to a rheumatologist if inflammatory markers are elevated or if symptoms persist despite initial management with NSAIDs like ibuprofen 400-600mg three times daily with food, which can be used for symptomatic relief while awaiting definitive diagnosis. Key points to consider in the workup include:
- Thorough history and physical examination
- Laboratory tests for inflammatory markers and autoimmune antibodies
- Imaging studies, including plain radiographs and potentially ultrasound or MRI
- Evaluation for other causes of morning symptoms, such as carpal tunnel syndrome or cardiac dysfunction
- Referral to a rheumatologist if necessary, based on findings and response to initial management.