A PAIR OF PAINFUL HANDS. A. Cooper 1 ; 1 University of Pennsylvania, Philadelphia, PA (Tracking ID #73721) LEARNING OBJECTIVES: 1. To review the American College of Rheumatology diagnostic criteria for rheumatoid arthritis (RA). 2. To discuss initial treatment of newly diagnosed RA. CASE INFORMATION: A 39 y/o homeless woman with a past medical history significant for hypertension, diabetes, hepatitis C, and asthma on no medications was admitted to the inpatient psychiatric unit for depression with suicidal intent. The medicine service was consulted for evaluation of hand pain. The patient had been having 2 months of progressively worse pain in both her hands, as well as 1 month of swelling and morning stiffness lasting 90 minutes before improvement. The symptoms made it difficult for her to make a fist or hold her cigarette. Over the last 1 week, all of her symptoms markedly increased. Additionally, she recently noted a sensation of numbness and tingling in her first three fingertips of the right hand that wakes her from sleep. The patient denied any fevers, chills, night sweats or other joint involvement. She denied dry eyes or mouth, as well as urethritis/vaginitis. Review of systems in detail was otherwise negative. Social history was significant for a 20 pack year smoking history. Family history was noncontributory. Physical exam was significant for bilateral symmetric swelling, mild erythema and boggy tenderness of 8 proximal interphalangeal joints. There was no involvement of the distal interphalangeal joints or thumbs and minimal tenderness of the MCP joints. There was no wrist tenderness. Remainder of the joint exam was unremarkable. Remainder of the physical exam was significant for a blood pressure of 130/90, mild expiratory wheezes bilaterally at the lung bases, and a positive Phalen's sign. Pertinant negatives included a temperature of 97.9, moist mucous membranes, no cardiac murmurs, no rashes or nodules and a negative Tinel's sign. Laboratory results were significant for normal electrolytes, renal function, TSH, WBC and hemoglobin levels. The ESR was normal at 9. Anti-Scl 70, dsDNA, and complement levels were normal. The ANA was weakly positive at 1:160. The patient had a positive RF of 104 IU/mL (normal 0±29 IU/mL). Parvovirus IgM was negative, as were Hep B serologies and HIV. IMPLICATIONS/DISCUSSION: Discussion: This patient was diagnosed with early moderately severe RA. The American College of Rheumatology criteria for diagnosis of RA were initially developed to help classify patients for clinical studies. However, they have proved useful in diagnosis as well. The guidelines are as follows: A patient has RA if at least 4 of these criteria are met (the 1st 4 of which must have been present at least 6 weeks): 1) Morning stiffness, usually lasting at least 1 hour before maximal improvement. 2) Arthritis of at least 3 or more joint areas. 3) Arthritis of hand joints. 4) Symmetric arthritis. 5) Rheumatoid nodules. 6) Serum rheumatoid factor. 7) Radiographic changes±erosions, unequivocal bony decalcification adjacent to affected joints. Radiographic changes are present in 15% of patients in the 1st year of disease, in >90% of patients after the 1st 2 years. The initial diagnosis of RA may be difficult because early RA may satisfy few of the diagnostic criteria. Additionally, systemic lupus erythematosis, Sjogren's syndrome, and mixed connective tissue disease may also commonly present with a positive rheumatoid factor, and may be difficult to differentiate from RA early in the course of illness. Finally, seronegative RA, or RA presenting in a single large joint such as the knee, poses it's own obvious diagnostic dilemma. The diagnosis of RA is supported by findings of carpal tunnel syndrome, as seen in this patient, as well as weight loss, fever, anemia, serositis, pulmonary nodules and peripheral neuropathy. Therapy for RA is usually initiated with non-steroidal antiinflammatory drugs (NSAIDs). Prednisone is added for rapid improvement when severe joint symptoms are present, and is usually tapered after inflammation is controlled. Disease modifying anti-rheumatic agents (DMARDs) are added if symptoms are not controlled with NSAIDs, if symptoms are moderate or severe in nature, or if radiographic changes are present. DMARDS are medications that have been proven to reduce the rate of bony destruction in RA. The most common DMARD used for initial treatment is methotrexate, started at a dose of 7.5 mg/week. The maximum dose of methotrexate is 25 mg subcutaneously/week. It is important to monitor patients for methotrexate toxiticy including liver function tests (cirrhosis), pulmonary symptoms (interstitial lung disease), and bone marrow toxicity. LEARNING OBJECTIVES: 1) Apply epidemiologic factors to decisions of whether to screen for hepatocellular carcinoma (HCC) in chronically Hepatitis B-infected individuals. 2) Recognize the limitations of current screening modalities for HCC. CASE INFORMATION: An asymptomatic 23 year-old male student presents to clinic after being told by a former sexual partner that he had``given her an infection.'' He has no significant past medical or surgical history. His review of systems is negative. He was born in China and immigrated to the United States at two years of age. He uses a half-pack-per-day of tobacco, alcohol to intoxication 1±2 times per week, no recreational drug use. His physical examination is normal. His laboratory values are significant for being hepatitis B (HBV) surface antigen positive, surface antibody negative, core antibody positive, e antigen negative, and HBV viral load undetectable. Hepatitis C and Human Immunodeficiency Virus (HIV) are negative. His liver function tests are all within normal limits.