Rheumatoid Arthritis - Case Report

 

De&art$ent ' R(eu$at%)* Medi+ine ,a+u%t* Hasanuddin Uni-ersit*

Au)ustus 201.  

RHEUMATOID ARTHRITIS

Warren Lie – C11112007 Putri Hardianti Kustant – C11112070 RESIDE!T" dr## Meria$ dr Meria$ Me%inda

 

PATIE!T IDE!TIT/ Name  Age

: Mrs. S : 32 years old

Sex : Female O++u&atin " Husei'e

 

HISTOR/ • Chief complaint" int &ain • Further anamnesis" ,e%t sin+e 2 $nt(s a) and rsen in t(e &ast ee#

 T(e &ain'++urr ++urred ed in T(e t(e duratin $rnin)3'a++$&anied it( int sti4ness t(e ints# t(e sti4ness is $re $re t(an 50 $ $inutes# inutes# T(e sti4ness and &ain ere re%ie-ed 6* a+ti-it*# T(ere is n (istr* ' trau$a3 +u)(3 s(rtness ' 6reat(3 nausea3 -$itin) and +(est &ain# T(ere is (istr* 'e-er3 inter$ittent it( n +%ear &attern# S(e %st 2 ) ' 6d* ei)(t it(in t(e %ast $nt( 6e+ause ' de+reased a&&etite# Histr* ' treat$ent in a )enera% &ra+titiner3 s(e as )i-en ana%)esi+s 6ut t(ere is n i$&r-e$ent#

 

PH/SICAL PH/SIC AL EAMI! EAMI!A ATIO! Vital Sign   8P" 100970 $$H) RR " 20:9$in   HR" ;@3 nr$a% nr$a%  – Pa%&at %&ati in n " ! $a $ass ss9t 9ten ende derrness ness33 %i-er i-er and s&%een are nt &a%&a6%e  – Per er+ussi +ussin n " T*$&an T*$&anii >@3 >@3 n as+ite as+ites s

 

RHEU RH EUMA MATO TOL LO/ ST STA ATU TUS S •  AIT" nr$a% •  ARM"

?   PIP I – B D9S tenderness >@3 ede$a >?@3 san ne+ >?@3 6utunniere de'r$it* >?@ ?   MCP I – B D9S tenderness >@ ?   Wrist D9S tenderness >@ •  LE" nr$a% •  SPI!E" nr$a%

 

LA8ORATORIUM %A&AMETE&

&ES'$T

N!&MA$ VA$'E

'NT

W8C

.#<

= &ints@ • Duratin ' s*$&t$s  . ees >1 &int@

ACR?EULAR CLASSI,ICATIO! CRITERIA ,OR RA" ( ) %!NTS  &A 

 

!O DATA

!O DATA

 

PRO8LEM LIST >1@ &HE'MAT!# A&TH&TS P%an" - ?ra* ' (and and rist ints D D9S 9S AP9%atera% - La6ratriu$" R,9ACPA3 ESR

 

PRO8LEM LIST >1@ &HE'MAT!# A& &HE'MAT!# A&TH&T TH&TS S !n?&(ar$a+%)i+ t(era&*" - ,is( i% su&&%e$ent - P(*si+a P(*si+a%% e:er+ise e:er+ise P(ar$a+%)i+ t(era&*" - DMARDs" Met(tre:ate 10$)9ee - ,%i+ a+id 1 $)9da* - !SAID" Me%:i+a$ 73= $)9da* PPI" $e&ra%e 2@ ANEMA N!&M!C*TC N!&M!CH&!MC • H6 10#2 $)9dL 5

• MCB ;0#1 u$ • MCH 2;#2 &) P%an" - treat under%*in) +ause + ause >RA@ - Peri&(era% 6%d s$ear - i' H6 dr&s 6e% 103 in-esti)ate 'urt(er  irn3 8123 '%ate studies 

 

#i+erential #iagnosis Characterist ic ,ender

&heumatoid Arthritis ,e$a%e  Ma%e

!steoarthritis

,out Arthritis

,e$a%e  Ma%e

Ma%e  ,e$a%e Men " 5= *ears

Age

20 ? =0 *ears %d

 =0 *ears %d

W$en " a'ter $en&ause

InJa$$atin in $u%ti&%e ints3

Pain  se%%in) n $ar ei)(t 6earin) ints3 sti4ness3

A t*&e ' art(ritis t(at +auses inJa$$atin3

$rnin) sti4ness  50 $ins

+re&itatin3 usua%%* in ne int3 tenderness3 t(at 6e)ins $rnin) sti4ness G sudden%* 50 $ins Wei)(t 6earin) 1st S$a%% ints >PIP3 MCP3  ints >)enu3 (i&3 Metatars&(a%an)e $ocation MTP@ -erte6ra@ a% ints S-mmetrical S*$$etr* As*$$etr* As*$$etr* S-mptoms

%athological  

Additional %h-sical • -

E.amination

nspection : De'r$it* ' t(e ints >San !e+ de'r$it*3 8utnniere de'r$it*3 u%nar de-iatin@

 

RHEUMA RHEUMATOID TOID AR ARTHRITIS THRITIS

#SC'SS!N

 

#EFNT!N R(eu$atid art(ritis >RA@ is a +(rni+ inJa$$atr* disease ' unnn eti%)* $ared 6* &eri&(era% &%*art(ritis#

s*$$etri+3

 

E%#EM!$!,* • $an  $an 2?5"1 • In'e+tin 'a+tr • Heat s(+ &rtein

 

%ATH!%H*S!$!,* 

 

C$NCA$ FEAT'&ES A&TC'$A& • Ear%* $rnin) int sti4ness3 easin) it( &(*si+a% a+ti-it* • Pr Predi%e+tin" edi%e+tin" rist3 MCP3 PIP ints# DIP rare# • U%nar de-iatin3 tri))er n)ers3 san?ne+ de'r$it*3 6utnniere de'r$it*3 ?%ine de'r$it*

 

C$NCA$ FEAT'&ES EXT&AA&TC'$A& - Cnstitutina% - !du%es - S)ren s*ndr$e - Pu%$nar* - Cardia+ - Bas+u%itis - He$at%)i+ - L*$&($a

 

#A,N!SS C&TE&A

 

THE&A%*  • NSA#s • ,lucocorticoids " &rednisne 10 $)9d • #MA&#s - Met(tre:ate 10?2= $)9 - LeJun$ide 10?20 $)9d - Su%'asa%aine =00$) 2:1  1000?1=00$) 2:1 - H*dr:*+(%rNuine 200?