Department of Rheumatology

Medicine Faculty
Hasanuddin University

Augustus 2016

RHEUMATOID ARTHRITIS
Warren Lie C11112007
Putri Hardianti Kustanto C11112070
RESIDENT:
dr. Meriam Melinda

PATIENT IDENTITY
Name
: Mrs. S
Age
: 32 years old
Sex
: Female
Occupation : Housewife

HISTORY
Chief complaint: joint pain
Further anamnesis:
Felt since 2 months ago and worsen in the past week.
The joint pain occurred in the morning, accompanied
with stiffness of the joints. The duration of the stiffness
is more than 30 minutes. The stiffness and pain were
relieved by activity. There is no history of trauma,
cough, shortness of breath, nausea, vomiting and chest
pain. There is history fever, intermittent with no clear
pattern. She lost 2 kg of body weight within the last
month because of decreased appetite. History of
treatment in a general practitioner, she was given
analgesics but there is no improvement.

PHYSICAL EXAMINATION
Vital Sign
BP: 100/70 mmHg
RR : 20x/min
HR: 84x/min, regular T : 36.5 oC
Head: anemia (-), jaundice (-)
Neck: JVP R+0 cmH20 (30o)

PHYSICAL EXAMINATION
CHEST EXAMINATION
Inspection : symmetrical, no scar, ictus cordis
not visible
Palpation : no mass/tenderness, apex not
palpable
Percussion : normal heart size, liver border ICS 6
Auscultation :
Lung : vesicular breath sound
Rh -/- Wh -/Heart : S1 S2 regular, murmur (-)

PHYSICAL EXAMINATION
ABDOMINAL EXAMINATION
Inspection : Flat, follow breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass/tenderness, liver and
spleen are
not palpable
Percussion : Tympani (+), no ascites

RHEUMATOLOGY STATUS
GAIT: normal
ARM:
PIP I V D/S tenderness (+), edema
(-), swan neck (-), boutunniere
deformity (-)
- MCP I V D/S tenderness (+)
- Wrist D/S tenderness (+)
LEG: normal
SPINE: normal

LABORATORIUM
PARAMETER

RESULT

NORMAL
VALUE

UNIT

WBC

6.4

4.0 10.0

10^3 u/L

HGB

10.8

13.0 17.0

g/dL

MCV

80.1

80-100

um3

MCH

28.2

27-32

pg

PLT

240

150 - 500

10^3 u/L

Ureum

22

10 - 50

mg/dL

Creatinine

0.8

<1,3

mg/dL

SGOT

20

<38

U/L

SGPT

21

<41

U/L

Glucose

98

<140

mg/dL

PROBLEM LIST (1)

RHEUMATOID ARTHRITIS
Joint pain + stiffness in the morning
Stiffness duration > 30 mins, relieved by
activity
Tenderness in more than 10 joints (PIP I V
D/S, MCP I V D/S, wrist D/S (5 points)
Duration of symptoms > 6 weeks (1 point)
ACR-EULAR CLASSIFICATION CRITERIA FOR RA:
> 6 POINTS RA

NO DATA

NO DATA

PROBLEM LIST (1)

RHEUMATOID ARTHRITIS
Plan:
- X-ray of hand and wrist joints D/S
AP/lateral
- Laboratorium: RF/ACPA, ESR

PROBLEM LIST (1)

RHEUMATOID ARTHRITIS
Non-pharmacologic therapy:
- Fish oil supplement
- Physical exercise
Pharmacologic therapy:
- DMARDs: Methotrexate 10mg/week
- Folic acid 1 mg/day
- NSAID: Meloxicam 7,5 mg/day
- PPI: omeprazole 40mg/d

PROBLEM LIST (2)

ANEMIA NORMOCYTIC NORMOCHROMIC
Hb 10.2 mg/dL
MCV 80.1 um3
MCH 28.2 pg
Plan:
- treat underlying cause (RA)
- Peripheral blood smear
- if Hb drops below 10, investigate further
iron, B12, folate studies

Differential Diagnosis
Characterist
ic
Gender
Age

Rheumatoid
Arthritis
Female > Male
20 - 50 years old

Osteoarthritis

Gout Arthritis

Female > Male

Male > Female

> 50 years old

Men : >35 years

Women : after
menopause

Pain & swelling on

major weight
A type of arthritis
Inflammation in
bearing joints,
that causes
multiple joints,
stiffness,
inflammation,
Symptoms
morning stiffness >
crepitation,
usually in one joint,
30 mins
tenderness,
that begins
morning stiffness <
suddenly
30 mins
Weight bearing
1st
Small joints (PIP, MCP,
Location
joints (genu, hip, Metatarsophalange
MTP)
vertebra)
al Joints
Symmetrical
Symmetry
Asymmetry
Asymmetry
Pathological

Additional Physical
Examination

Inspection :
Deformity of the joints (Swan Neck deformity,
Boutonniere deformity, ulnar deviation)

RHEUMATOID ARTHRITIS

DISCUSSION

DEFINITION
Rheumatoid arthritis (RA) is a chronic
inflammatory disease of unknown
etiology
marked
by
symmetric,
peripheral polyarthritis.

EPIDEMIOLOGY
woman > man 2-3:1
Infection factor
Heat shock protein

PATHOPHYSIOLOGY

CLINICAL FEATURES
ARTICULAR
Early morning joint stiffness, easing
with physical activity
Predilection: wrist, MCP, PIP joints.
DIP rare.
Ulnar deviation, trigger fingers,
swan-neck deformity, boutonniere
deformity, Z-line deformity

CLINICAL FEATURES
EXTRAARTICULAR
- Constitutional
- Nodules
- Sjogren syndrome
- Pulmonary
- Cardiac
- Vasculitis
- Hematologic
- Lymphoma

DIAGNOSIS CRITERIA

THERAPY

NSAIDs
Glucocorticoids : prednisone 10 mg/d
DMARDs
Methotrexate 10-25 mg/w
Leflunomide 10-20 mg/d
Sulfasalazine 500mg 2x1 1000-1500mg 2x1
Hydroxychloroquine 200-400 mg/d
Biologic DMARDs
TNF-alpha inhibitor: Infliximab, Etanercept, Adalimumab,
Golimumab, Certolizumab
- Abatacept
- Rituximab
- Toclizumab

THANK YOU.

REMISSION CRITERIA
ACR
1. Stiffness in the morning less then 15
minutes
2. No fatigue
3. No joint pain
4. No pain on pressure or in movement
5. No swelling of joint
6. ESR lessthan 20mm/ hour for the male,
30mm/hour

AKTIVITAS NILAI
NILAI
PENYAKIT DAS28-LED DAS28CRP
REMISI
2,6
2,3
RENDAH
3,2
2,7
SEDANG
>3,2 S/D
>2,7 S/D
5,1
4,1
TINGGI
>5,1
>4,1