RHEUMATHOID

ARTHRITIS
Presented by:
Miftahussurur
C111 11 340
Andi Riza Syafitri
C111 13 553

Reumatology Division of Internal Medicine Department

Hasanuddin University
Makassar 2017
Name : Mrs. A
Age : 55 years old
Date of Admission : 27 February 2017
Address : Jl. Wortel No 4
Job : Housewife
Room : Rheumatology Polyclinic
Medical Record : 791536
 Chief complain: Pain in the joints
Patient felt pain in hand and foots joint since 14 years ago
and increasing for the last 1 year, patient often came to
hospital in sorowako and being told that she had high level
of uric acid and rheumatoid arthritis in her finger. She often
felt stiffness in her finger in the morning for 1 hour and
sometime there was swelling. Cramped in hands and foot.
There was no fever, cough, shortness of breath and chest
pain. Defecation is normal, urination is normal. The patient
took methylprednisolon only if she felt pain since one year
ago.
History of high uric acid 14 years ago, controlled by
allopurinol but not taking regularly, last time her uric
acid was 7. No history of HT, DM, heart disease. There
was history of trauma and fracture at the right wrist.
General Description

Moderate illness/well nourished/ compos mentis

Vital Signs

BP: 110/70 mmHg

HR: 83x/min

RR: 24x/min Temp: 36,5C

BW: 49 kg BH: 152cm

BMI: 21.21kg/m2
Head
Deformity: None
Symmetrical face: symmetric
Hair: Hard to remove
Size: Normocephal
Shape: Mesocephal
Eyes
Conjunctiva: Pale (-)
Cornea: corneal reflex (+)
Sclera: Jaundice (-)
Pupils: Isokor 2,5 mm / 2,5 mm
Mouth
Lips & tongue: Dry (-), dirty (-)
Tonsils: T1-T1 No hyperemia
Faring: Not hyperemia
Neck
Lymph Nodes: No Enlargement
JVP: R+1 Cm
Chest Lung Heart
Shape: Symmetrical I: Symetrical left & right I: Ictus cordis does not seen
between left and right P: Fremitus symmetrical P: Ictus cordis palpable,
Breasts: Symmetrical with the same left-right thrill (-)
approximately equal to Tenderness (-) P: Right heart border in ICS
the right, no P: Sonor on both lung fields IV linea parasternalis
abnormalities A: Vesicular sound dextra;
Between the ribs: Additional sounds: Left heart border in ICS
Symmetrical between left ronkhi (- / -), V linea medioclavicularis
and right wheezing (- / -) sinistra
A: S1/S2 pure, regular. No
gallop, no murmur
Abdomen
I: Convex, follow the motion of breath
A: Peristaltic (+) normal impression
P: Liver and spleen are not palpable
P: Tympani (+), no ascites

Extremity
No pitting edem
 Gait: Antalgic

Arm:
Elbow : no sign of inflammation. Rom normal. Nodule rhematoid(-)

Manus :
Dextra: MCP 1,2, tenderness (+) rubor, swelling, warm,
Z thumb deformity and bottuniere deformity at digiti V.
Wrist : tenderness. Limited ROM at passive and active movement. Ulnar
deviation
Sinistra: Deformities in MCP 2,4 ,tenderness (+),swelling,warm.bottuniere
digiti 5.

Legs: normal

Spine: Normal
Tests Results Tests Results
FBG 105 WBC 6.61
Ureum 20 RBC 5.51
Creatinin 0.85 Hgb 14.6
SGOT 38 HCT 43.8
SGPT 34 MCV 79.5
Total 227 MCH 26.5
cholesterol
HDL 50 MCHC 33.3
LDL 123 PLT 359
Trigliserida 104 NEUT 3.97
Uric Acid 7.9 LYMPH 2.08
RF 392.2 MONO 0.50
Quantitative 24.7 EOSINOFIL 0.04
CRP
 Bone alignment that formed bilateral manus not intact

Flexion and extension of digiti I,IV,V bilateral manus

shows swan neck appearance with narrowing of
proximal interphalangeal joint IV V manus dextra

Bone mineralization decrease in periarticular area

Joint space of other MCP, PIP and DIP are normal

Soft tissue normal

1. Rheumatoid Arthritis (DAS 28-CRP score 3.83)
based on:
Symmetrical arthritis
There are arthritis in hands more than one (MCP, PIP)
Stiffness in the morning more than one hour
Z thumb deformity and bottuniere deformity at digiti
V manus dextra; and bottuniere deformity at digiti V
manus sinistra
Positive RF (392.2)
 Plan diagnostic :
-

Plan therapy :
Methylprednisolon 4mg/12hrs
Methotrexat 2,5 4tab/week
Folic acid 0,4mg/24hrs
Meloxicam 7,5/24hrs/ if needed
 Based on this patient, we diagnosed as
rheumatoid arthritis.
So, RA is a chronic systemic autoimmune
disease charactherized by inflammatory
polyarthritis which affects peripheral joint
especially small joint of the hand.
Chronic untreated inflammation may lead to joint
erosions and joint destruction.
 EPIDEMIOLOGY

In this case, the patient was female, the most cases was
reported that supposedly more common in women than
men ( female: male ratio of 3: 1).

Stated that peak onset is in fourth or fifth decade for

women and the sixth to eight decade for men,
eventhough this patient is woman age 55 years old,
there is possibility to get this RA.
 Clinical manifestation
Based on this patient, the clinical manifestation is list below :

1) Onset of joint pain

2) Almost all of the hands joint
3) Early morning stiffness ( lasting more than 1 hour)

Based on theory, there is an additional symptom on RA :

1) Joint pain, tenderness, swelling of stiffness for six weeks or longer
2) Joint stiffness that is usually worse in the morning and after inactivity.
3) Most common joints involved include MCP, PIP, wrists, MTP,ankles, elbows,
shoulders, hips and knees .
4) DIP joints, sacroilic and vertebral joints are spared except for C1 to C2.
5) Characteristic deformitis in hands with long-standing uncontrolled disease,
including : - swan neck deformity
- the boutonniere or button hole deformity
- Z deformity of the thumb
6) As the disease progresses threre is weakening of joint capsules
- joint instability
- subluxation
- deformity
 Systemic

Heart and
peripheral Eyes
vessel

Non-articular
Hematological manifestation of neurological
RA

kidney pulmonary

vasculitis
 Laboratory test

Synovial fluid Radiology

test imaging

Immunological
test
 Management
For this patient, we give pharmacological treatment as below :
- Methyl prednison 4mg/12hours/oral
- Hydroxychloroquin

But, American College of /rheumatology (ACS 2015) stated that

DMARDS as first line treatment.
1) DMARD (disease modifying anti reumatic drugs)
- Methotrexate - Leflunomide
- Hidroxychloroquin - sulfasalazin
- Infliximab - Etanercept
2) Corticosteroid
3) NSAIDS
 Constitutional
Insidious onset Nodules
symptoms

Multiple swollen and

tender joints at
RF positivity with high
presentation (high
titres
disease burden, high
DAS).