AUGUST 2016

RHEUMATOID ARTHRITIS
Presented by:
Yuliasi/C11112018
Nurul Indah Pertiwi/C11112052
Resident:
dr. Nurhidayah Asjuh

Department of Rheumatology
Medicine Faculty
Hasanuddin University

PATIENT IDENTITY
Name
Age
Sex

: Mrs. F
: 27 years old
: Female

HISTORY
Chief complaint: Interphalangeal joint pain,
wrist joint pain, shoulder pain
Further anamnesis:
Felt since 2 years ago and worsen in the 2 past
weeks. There is history of hospitalized with same
symptoms. There is no history of trauma,
shortness of breath, nausea, vomiting and chest
pain. There is history of fever and cough,
intermittent with no clear pattern. There is history
of influenza several weeks ago. There is history of
swelling in the hands. She lost body weight
because of decreased appetite.

PHYSICAL EXAMINATION
Moderate illness/Normoweight/Composmentis
Weight : 5O kg
Height : 160 cm
BMI
: 19,5 kg/m2

Vital Sign
BP : 110/80 mmHg
RR : 18x/minute
HR : 112x/minute
Temp : 37.80 C
NRS
: 2/10

PHYSICAL EXAMINATION
Head: anemia (-), jaundice (-)
Neck: JVP R+0 cmH20 (30o)
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 warm, tenderness (+), swelling (+)
- MCP I V D/S eritema, tenderness (+)
- Wrist D/S tenderness (+)
LEG : Genu D/S normal
SPINE
: normal

LABORATORIUM
PARAMETER

RESULT

NORMAL
VALUE

UNIT

WBC

3.6

4.0 10.0

10^3 u/L

HGB

10.2

13.0 17.0

g/Dl

PLT

219

150 - 500

10^3 u/L

RF

11

<15

IU/mL

CRP

9,4

0 - 10

Mg/dL

SGOT

50

<38

U/L

SGPT

27

<41

U/L

Glucose

90

<140

mg/dL

ESR

130/>130

PROBLEM LIST
RHEUMATOID ARTHRITIS
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

PROBLEM LIST
RHEUMATOID ARTHRITIS
Plan:
- X-ray of hand and wrist joints D/S AP/lateral
Hb 10.2 mg/dL
WBC 3,6 x 103 u/L
SGOT 50 U/L
Plan:
- treat underlying cause (RA)
- PBS
- 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
phenomeno
Autoimmune
Degeneration
Metabolic

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
Protein heat shock

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
Anakinta
Rituximab
Toclizumab

REMISSION CRITERIA
1.
2.
3.
4.
5.
6.

Stiffness in the morning less then 15 minutes

No fatigue
No joint pain
No pain on pressure or in movement
No swelling of joint
ESR less than 20mm/hour for the male,
30mm/hour

THANK YOU.