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Dr. Rick, MD
Dr. Rick, MD, Board Certified MD
Category: Medical
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Experience:  20+ years as a doctor. Internal Medicine Internship in NYC
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Pain and stiffness in all DIP and PIP joints

Customer Question

Since June I have developed pain and stiffness in all the joints of all my fingers. At first, it is most noticeable when I first wake up, then shortly subsided. Now the stiffness is present sometimes throughout the day.

Further, now when I make a fist my middle finger joints crack. I don't have any visible swelling except for the top joint in my right small finger. That finger hurts when I apply pressure on it and the joint is raised and the end of the finger is pointed down at about a 45 degree angle at the distal phalanx joint.

I have seen two rheumatologists. One said I had inflammatory arthritis (erosive arthritis) while the other disagreed, stating she believe it was "just" osteoarthritis.

The first rheumatologist ordered the following tests:

erythrocyte sedimentation rate, C-reactive protein level, rheumatoid factor

When I asked for the results, I received the following response from the first rheumatologist:

Your CRP was mildly elevated but that is not specific for anythingYour other tests were all normal


Questions: How do I determine which diagnosis is correct?

Can I be confident I don't have RA? Should I request an Anti-CCP tests to rule out RA or is that not necessary? I have read where the RA factor test is not very reliable for diagnosing RA early in the disease.

The first doctor recommended exercising my hands; e.g., squeeze ball; doing dishes; the second doctor actually recommend against that except for just very brief exercise of the hands.


P.S. Here is radiologist's impression from 9/28/12 X-Ray of right hand:


Bones: There is no apparent fracture. No osseous lesions are identified.

Joints: Osseous alignment is maintained. There is mild narrowing
of the interphalangeal joints most severely affecting the DIP of
the fifth digit with mild osseous spurring. An inflammatory arthritis is suspected.

Soft tissues: The soft tissues are grossly unremarkable. No
radiopaque foreign bodies are seen.

IMPRESSION:

Interphalangeal joint space narrowing most severely affecting
the DIP of the fifth digit with secondary osseous spurring; an
early inflammatory arthritis is suspected.


 


Male: Age 56

Submitted: 1 year ago.
Category: Medical
Expert:  Dr. Thomas, MD replied 1 year ago.
Hello from JA
Sure
Get an MRI of the hands.
This will show if this is RA or osteo.

\

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Customer: replied 1 year ago.


Ok, thanks. But why didn't either doctor recommend an MRI?


 


Should I request an Anti-CCP tests to rule out RA or is that not necessary?


 


And if not RA, how do I determine whether my condition is inflammatory arthritis (erosive arthritis) or "just" osteoarthritis.


 


Thank you.

Expert:  Dr. Thomas, MD replied 1 year ago.
You can get the antibody test but it is still not as definitive as the MRI.
Inflammatory arthritis and osteo are not a clear distinction. Osteo can be inflammatory to a degree.
Again, the MRI.

I can not address why you doctors have not done this.


Please click on one of the positive ratings [smiley faces]: the only way we are compensated for time and expertise. If you are not done or satisfied, use reply to expert [not poor/negative]. Come back anytime. Bonuses are great…but your satisfaction is my goal.

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Customer: replied 1 year ago.


Please opt out. Thank you.

Expert:  Dr. Rick, MD replied 1 year ago.
I see that your expert has opted out and is no longer available to assist you.

How can I help?
Customer: replied 1 year ago.

Hello,


 


I would appreciate if you read my original question and provide a reply if you have experience in this area. Thank you.

Expert:  Dr. Rick, MD replied 1 year ago.
In instances like this where two experts give you conflicting results from a similar exam, the only thing to do is to obtain a third opinion from another expert with the same qualifications.

This would require another physical examination and, as I'm sure you will agree, can not be done using online "chat" as the only diagnostic tool.

At this point I think the best thing for you to do would be to gather up copies of all your medical records and travel to a large University Teaching hospital. At an institution like that you could be evaluated and treated by a team of sub-specialists who are at the cutting edge of their respective fields. The best thing about these large teaching hospitals is that consultations are available with Professors and leaders in their field by just walking a few steps down the hall.

The Mayo Clinic in Rochester, Minnesota is an excellent example of just such a place as this. That being said there are many excellent teaching hospitals all across the country and I am sure that there is one near you.

If you could tell me what large city you live near and how far it would be possible for you to travel in seeking treatment I would be happy to give you some names. Of course, you could also ask friends and associates or check the internet yourself. Let me know what you would like to do.

Is there anything else you would like to discuss at this point or have all your questions been answered to your satisfaction?

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. And please let me know if the rating system gives you any troubles.

Thanks in advance,

Dr. Rick
Customer: replied 1 year ago.


My first rheumatologist was Dr. Nancy Lane from a highly rated teaching hospital, UC Davis. The second rheumatologist was a long time rheumatologist from the Sutter Medical Group in Sacramento, JaNahn C. Scalapino, M.D. Both are board certified.


 


I was hoping that you could respond with recommendations on what to ask for to be able to differentiate between the two diagnosis, or to rule out rheumatoid arthritis. Are you an orthopedist? Thank you.

Expert:  Dr. Rick, MD replied 1 year ago.
I actually went to UCD....it is a small world, eh?

I still believe your best course of action is to go to a third rheumatologist, with all your medical records in hand, have another complete examination and request another opinion.

When it comes to making a distinction between inflammatory arthritis and osteoarthritis there is no clear dividing line. This is may be why you are getting conflicting answers from two highly qualified doctors.

It's safe for you to press the positive feedback button now if you so desire. And, never fear, even after you press that button I don't go up in a puff of smoke -- I'll still be right here to continue helping you, but, as I do work for tips, I want to make sure you are happy before rating me
Dr. Rick, MD, Board Certified MD
Category: Medical
Satisfied Customers: 8525
Experience: 20+ years as a doctor. Internal Medicine Internship in NYC
Dr. Rick, MD and 6 other Medical Specialists are ready to help you
Customer: replied 1 year ago.

Ok, but can I be assured that I don't have RA after these two visits? Right now I am told there is nothing I can do about my condition; it will progress or not progress regardless of my actions. Do you agree with this?


 


Would you recommend either an anti-CCP antibody test to rule out RA


http://www.ccjm.org/content/79/4/249.full


 


and/or seek to obtain an MRI, or should I be extremely confident that I don't have RA based on my visits to these two board certified rheumatologist?


 


Thank you.

Expert:  Dr. Rick, MD replied 1 year ago.
You are correct....there is no cure for either of the two diagnostic possibilities you have been given. As such, a third opinion will,in the long run, probably not make any real difference at this point.

While the anti CCP test is very good I am sure that if either of the board certified experts you have already consulted thought it would add anything to their decision process they would have ordered it...the same goes for an MRI.

If I was in your shoes, I would just follow the advice of a board certified rheumatologist and stop trying to second guess them at what they are trained best to do....

Is there anything else you would like to discuss at this point or have all your questions been answered to your satisfaction?

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. And please let me know if the rating system gives you any troubles.

Thanks in advance,

Dr. Rick
Customer: replied 1 year ago.

But I am not second guessing them because they have come up with two different diagnoses. And some information on the net indicates that for OER that Remecade cause deformities to subside.


 


Further, OER is generally more aggressive and debilitating, and the doctor that diagnosed OER recommended hand exercises while the other that diagnosed OA expressed caution with regard to this activity.


 


Have you heard of an MRI being valuable to distinguish either from RA or to distinguish OER from OA? Thank you.

Expert:  Dr. Rick, MD replied 1 year ago.
I do not think that any one test is going to clear up this for you.

It seems clear that your best option is to obtain a third opinion and discuss it with that doctor.

I understand your concerns but the internet is not going to be where you are going to get the answers you seek.

Is there anything else you would like to discuss at this point or have all your questions been answered to your satisfaction?

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. And please let me know if the rating system gives you any troubles.

Thanks in advance,

Dr. Rick
Customer: replied 1 year ago.

That is what I am looking for you to assist me with. Are you an orthopedist?


 


I am looking for what criteria I should look for to distinguish which condition I have so when I meet with another rheumatologist I will be an educated patient. I was somewhat taken aback when neither rheumatologist placed my x-ray against a lighted back screen to examine. They just looked at the film by holding it up to the ceiling light and never did respond to my query regarding the degree of erosion or cartilage loss they saw. I don't think the first doctor would have even ordered the blood tests if I wasn't insistent.


 


And the internet has knowledge that many doctors are not aware of so don't dismiss it so fast. For example, my primary care doctor had no knowledge of a free PSA test, although that severed as a main criteria for the urologist ordering a biopsy, and I have had urologists make diagnosis that were not reliable based not only on information on the internet but in medical textbooks. If a web site is reliable such as Medline, the information should not be just discarded because it came from the "internet".

Expert:  Dr. Rick, MD replied 1 year ago.
While I know it seems strange that you can get information from an X ray by holding it up to the room light, it is indeed possible. Also, there is always an official report from a radiologist that comes with every xray taken. In this regard I would not worry that your xrays were "glossed over" in any way.

While there may be information on the internet about your condition that a GP may not be aware of I can assure you that a specialist, such as the two rheumatologists you have consulted with, knows everything about your condition and Mr. Google has no new data to offer a MD with this level of advanced training.

In my opinion, you are a very well informed patient. In medicine, as in life, there is often no "right" or "wrong".....just lot's of gray. And that is precisely where your medical condition is right now.

You can search the internet and consult with many medical experts and, I believe, you will just get more information -- never reaching that one "right" answer.....because in a world of Grey, right and wrong have vague meanings.

As I stated before, if you are still concerned, you should see another well-respected rheumatologist and then "pick" the best answer out of the three offered and go with it.

It's safe for you to press the positive feedback button now if you so desire. And, never fear, even after you press that button I don't go up in a puff of smoke -- I'll still be right here to continue helping you, but, as I do work for tips, I want to make sure you are happy before rating me.

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