Case 1: 8/31/17

SIQORAAA:

 Site of pain
o Fingers and wrists
 Intensity of pain
o 5/10 to recently 7/10
 Quality
o Stiffness and dull aching pain
 Onset of pain
o 4 months ago
 Radiation
o Was localized to joints of fingers and wrists but moved to feet
 Alleviation
o Activity and 800 mg ibuprofen
 Aggravation
o Present when waking up in morning and lasts until midmorning
 Associated Manifestations
o Knuckles and wrists are swollen and slightly discolored

PAM R. FOSS

 PATIENT MEDICAL HISTORY

o Hospitalized for appendectomy at age 12
 Allergies
o Seasonal hay fever
 Medication
o BC pills and ibuprofen
 Review of Symptoms
o Relevant positives:
 Several months of intermittent low grade fever, loss of energy, fatigue,
decreased appetite, unintentional 5 lbs. weight loss
o Relevant negatives: denies changes in bowel habits or rashes on the skin
o Vital signs
 Heart rate: 70 bpm
 BP: 110/72
 Respiratory rate: 12 breaths per minute
 Temp: 37
 Weight: 60 kg (132 lbs)
 Height: 164 cm (5’4”)
 BMI: 22.7 (normal)
 Tympanic membrane slide 13
 o Throat: moderate gingivitis of teeth
o Extremities
 MIP, PIP, and wrist joint are slightly red, mildly swollen and tender
 DIP is normal
o Lab values
 WBC count: 7500x10^3/mm^3
 59% segmented neutrophils
 1% banded neutrophils
 32% lymphocytes
 4% monocytes
 3% eosinophils
 Hemoglobin: 11 g/dl Hematocrit: 33%
 Platelet Count: 500,000/mm3
 **Erythrocyte sedimentation rate (ESR) = 42 mm/hour
 Normal: 0-29 mm/hr for women
 Her test is high
 C reactive protein (CRP) = 3 mg/dL Rheumatoid Factor (RF) = positive
 Normal: <3.0 mg/dL
 **Anti-cyclic citrullinated peptide antibody (anti-CCP) = 89 U/ml
 Normal: less than 20 u/mL
 Her test is high
 Family history
o Mother had arthritis, not sure of what type
 Obstetric history
o Never been pregnant
o Menarche at age 12
o Regular menstrual cycles with last one being 2 weeks ago
 Social history
o Smokes 1.5 packs of cigs/day since age 21
o Drinks 1-2 drinks on the weekend
o Works as a law clerk
 Sexual history
o One sexual partner in monogamous relationship

Common causes of joint pain

 Osteoarthritis
 Gout
 Rheumatoid arthritis
 Bone cancer
 Hypothyroidism
Clinical presentation (history and findings) of RA
 Persistent symmetric polyarthritis that affects the hands and the feet
 Pts. With RA have difficulty performing activities of daily living
o Dressing
o Standing
o Walking
o Personal hygiene

Lab tests used to diagnose RA

 Erythrocyte sedimentation rate (ESR)
 CRP
 Anti-cyclic citrullinated peptide body (anti-CCP)

Radiographic features of RA

Definitions
 Rheumatoid nodules
o Local swelling or tissue lump that is frim to touch
 Pannus
o Abnormal layer of fibrovascular tissue or granulation
 Bouchard’s nodules
o Hard outgrowths or gelatinous cysts @ PIP
o More commonly seen in osteoarthritis
 Heberden’s nodules
o Bony swellings at the DIP
 Osteophytes
o Bone spurs
o Bony projections that form along joint margins
 Autoimmune disorder
o Abnormal immune response to normal body tissue

Pathophysiology of RA

Difference between RA and Osteoarthritis

 The main difference between osteoarthritis and rheumatoid arthritis is the cause behind
the joint symptoms. Osteoarthritis is caused by mechanical wear and tear on
joints. Rheumatoid arthritis is an autoimmune disease in which the body's own immune
system attacks the body's joints.