A 55 yr old with chronic inflammatory symmetrical polyarthritis

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Here is a case i have seen:

A 55 yr old male patient who was a toddy tree climber by occupation  came to opd with complaint of pain in multiple joints associated with restriction of movement 

 Patient was apparently asymptomatic 10 yrs back .Then he felt pain in bilateral knee joints which is associated with swelling.for which he used medication (proper records not available about medication)which gave him mild symptomatic relief but not completely cured his pain.

Patient went to multiple hospitals used different medications (no records available).Then gradually after 2 years it started involving his shoulder ,elbow ,wrist PIP, DIP, MTP ,ankle joint ( except hip joint)

The pattern of involvement couldn’t be properly explained by the patient.

Early morning stiffness present(30-40 min, relieved with work)

The joint pains were on and off  since 3 yrs and patient  was on medication (diclofinac 100 mg ,ranitidine)

Patient had history of left lower limb cellulitis last month which was managed by general surgery .

Not a known case of DM,Htn,Tb,CAD,CVA,asthma

Occasionally alcoholic,toddy drinker since 35 yrs

Beedi smoking since 15 years (1 packet/ day)

No significant family history 

GENERAL EXAMINATION 

VITALS

Temp-afebrile

Bp-140/90

Pulse-87bpm regular in rhythm 

Rr-17cpm

Pallor-present

No cyanosis,clubbing,koilonychia,lymphadenopathy 

Pedal edema-grade1 lf> rt

SYSTEMIC EXAMINATION 

RESPIRTORY SYSTEM 

B/l air entry present

Normal vesicular breath sounds

No added sounds

CVS

S1S2 heard

No murmurs

PER ABDOMEN

Shape- elliptical 

No local raise of temperature,tenderness

No organomegaly,

Bowel sounds -present

CNS EXAMINATION 

Higher mental functions normal

Sensory and motor system- intact

Reflexes- intact

Cranial nerves- intact 

RHEUMATLOGICAL EXAMINATION 

Lesions are articular type with swelling of joint

No h/o extrarticular manifestations such as eyes, chest, cns

No h/o rash with arthritis to rule of infection- gonoccocal and others such as sarcoidosis

Schimers test negative on 7/9/2020 to rule out Sjögren’s syndrome  left eye-25mm, right eye- 10 mm

Enthesitis sites

Costocondral junction- 1 and 6 : negative 

Asis, iliac crest, psis- negative

Greater trochanter, ischial tuberosity- negative

Tendoachilles insertion- negative 

Modified schobers test

Cervical rotation( normal > 70): normal

To rule out vasculitis

Ecchymosis/ palpable purpura - negative

Ulcer- negative

 To rule out psoriatic arthritis

Arthritis- positive

Back pain -negative 

Enthesitis- negative

Rash- negative

To rule out Sle

Lupus flare- negative

General- no fever, loss of appetite 

Rash- negative

Nephritis- negative

Arthritis- positive

Rheumatoid arthritis- EULAR criteria

Joint distribution:

> 10 joints ( atleast one small joint) : score of 5

Serology: RA factor negative: 0

Symptoms duration:

> 6 weeks: score of 1

Acute phase reactants:score of 1 

Crp raised

Esr raised  

Total: 7 ( > 6 diagnostic of RA)

JOINT EXAMINATION 

                  Tenderness             Restriction of movement 

               Lt          Rt                  Lt              Rt 

TMJ        +          +                     +               +

Shoulder:+           +                   +               +

Elbow     +           +                  -                 -

Wrist       +            +                 +              +

MCP       +            +                +              +

IPJ

Distal      -            -                +               +

Proximal+          +                 +              +

Hip        -           -                 -                 -

Knee     +            +               +               +

Ankle   +             +              +              +

MTP      +           +             +              +

Intertarsal+         +               +            +

Fixed flexion deformity of right knee

Fixed flexion deformity of left knee

Zdeformity

Right hand

Left 2 nd distal PIP showing swam neck deformity 

                                  

             Anti cccp antibody test

Diagnosis: Rheumatoid arthritis 

Treatment given:

1) Tab methotrexate 7.5 mg weekly once

2) Tab prednisolone 10 mg  od

3) tab ultracet po/ bd

4)Tab PCM 650 mg po/ od

5) inj optineuron 1 ampoule in 100 ml NS iv od

6) inj thiamine 1 ampoule in 100 ml NS iv od

7) egg white with protein powder