Rheumatoid Arthritis

Rheumatoid Arthritis

4 Personal history

مصيلحي male pt., 47 years old, from Abu-Kabir, married and has 4 off springs. He is mild cigarette smoker, he used to smoke 10 cigarettes per day for 10  years, with no other special habit of medical importance .He is  Rt. handed.

4 c/o

His complaint is pain in both hands, 10 years duration.

4 HPI

            The condition started 10 years ago by gradual onset and progressive course of pain which increase in early morning and decrease gradually with exercise, associated with stiffness that last for more than one hour & gradually resolves. The patient developed marked hand and foot  deformities with loss of normal joint function in both upper and lower limbs.

No symptoms suggesting CVS manifestations.

No symptoms suugesting chest manifestations.

No symptoms suggesting Neurological or ocular manifestations.

No symptoms suggesting anaemia.

No symptoms suggesting renal affection.

4 Past history

            No drugs, operation, disease (DM, HPN).

4 Family history

-          No consanguinity.

-          No similar condition in family.

-          No common disease in family.

4 General exam

-          The patient is fully conscious, well oriented for time, place and person. Average mood and memory. The patient is co-operative with average intelligence.

-          Temperature: 37.2^o c.

-          Bl. Pressure: 130/80.

-          Resp. Rate: 16/minute, regular, average depth, abdomino-thoracic.

-          Pulse: Regular, 72 beat/minute, average volume, no special character, equal on both sides, intact peripheral pulsation, vessel wall is not felt, no radiofemoral delay.

-          The patient looks well, average built, no cyanosis, pallor or jaundice. He is lying free flat comfortable in bed.

-          Head & Neck :joint exam (see later).

-          Upper limb: No palmer erythema+ complete joint exam (see later).

-          Lower Limb: No L.L. edema + complete joint exam (see later).

           

4 Local exam (peripheral joints):

4 By Inspection_

1)     Deformities

Big joints: in the form of flexion deformity in both elbows .

Small joints are affected in the form of:

§   Rt. Hand: flexion deformity at MCP joint , Fusiform deformity in the middle finger, flexion deformity at PIP joint  in the little finger.

§   Lt. hand: Ulnar deviation of fingers at MCP joint , Swan neck deformity in index, subluxation at PIP joint in the middle finger, fusiform deformity at PIP joint  in ring finger, flexion deformity at MCP joint  in the little finger.

§    Both Feet: shows flexion deformity at PIP joints.

2)     Wasting

UL: There is bilateral wasting with guttering specially in the right hand. Both thenar eminences show flattening.

LL: medial aspects of both thighs show loss of muscle bulk.

4 By Palpation__

- Synovium isn't felt by rolling.

- Both elbows and middle finger of Rt. Hand show subluxation.

- Mild tenderness at wrist, MCP, PIP.

- Coarse Crepitus in both elbows and knees.

4 By inspection & Palpation__

­          Skin : no erythema, no palmar erythema, no psoriasis, no nail pitting, no scars, no warmth.

­          Swellings: no evidence of bursopathy, no thickened synovium, no osteophytes, no S.C nodules, no PIP, MCP, wrist  or knee effusions.

­          Range of movement :

·         UL: Limitation of movement in both sides at all direction of movements both actively and passively:

vFingers: flexion, extension, abduction, adduction, opposition, hand grip.

vWrist: ulnar and radial deviation, flexion and extention.

vElbow: extension and flexion.

·         LL: normal range of movement .

4 Local exam (cervical and lumber vertebral column):

4 By Inspection_

No deformity, no limitation of movement (flexion, extension, medial and lateral rotation, right and left tilting).

4 By palpation

No tenderness over cervical or lumber spines

4 Local exam (special joints):

Temperomandibular joint:

­          Inspetion: no erythema, normal range of movement

­          Palpation : no displacement, no crepitus.

Sacroiliac joint :

No evidence of sacroiliitis.

4 Other Systems

1)     CVS: search for cardiomyopathy (Systemic congestion),pericardial effusion.

2)     Neuro: search for Entrapment neuropathy, atlanto-axial subluxation.

3)     Hematological: anemia or may be pancytopenia.

4)     Chest: search for pleural effusion, fibrosis, caplan's syndrome .

5)     Renal: search for nephrotic syndrome, CRF .

6)     Ocular: scleritis ,Sjogren's syndrome.

7)     Others: myopathy ,muscle wasting ,HSM.

4 Investigation

1)     CBC, ESR, CRP, RF.

2)     X-Ray for hands and feet.

3)     Synovial fluid analysis.

4 Treatment

1)     Anti-inflammatory: NSAIDs (aspirin, indomethacin, diclofenac, ….), Steroids.

2)     Disease-modifying drugs: Gold, D-penicillamine, Chloroquine, sulphasalazine, levamisol.

3)     Immuno-suppressive drugs: Azathioprine, methotrexate

4)     Other measure: intra-articular injection of cortisone, surgical (arthroplasty, arthrodesis)

4 Diagnosis :

A case of polyarthritis for D.D most probably Rheumatoid Arthritis

v Why Rheumatoid ?

-          Bilateral & symmetrical.

-          Affecting small peripheral joints with sparing of DIP.

-          Deformities.

v Diagnosis of R.A. (American Rheumatoid Association):

1.       Morning stiffness more than 1 hour.

2.       soft tissue swelling of 3 or more joints.

3.       S.C nodules.

4.       Swelling of PIP, MCP, or Wrists.

5.       Symmetrical swelling of joint areas.

6.       X-ray à erosion or osteopenia in hand or wrist.

7.       R.F. is +ve.