Rheumatoid Arthritis Symptom

Rheumatoid Arthritis Patient Presentation

History

Mr.TT is a 49 year old single female, who works as a computer programmer. She is unable to commute to work, and is currently working from home. She lives with her 2 children in a three-storey home.

Reason for Referral

Mrs. TT has been referred from her family doctor for multiple arthralgias.

Mrs. TT experienced an insidious (over months) onset of multiple joint pains, involving both her large and small joints. Important aspects on history were her age and gender, 49 year-old female, and learning that the onset and duration of her joint pains were over a year, with gradual worsening over time and an accumulation of multiple joints. She described times in which she would have severe night pain, and difficulties getting out of bed and cooking. These episodes would last for a couple of weeks, and she would then return to her previous condition, in a waxing and waning pattern with slow deterioration/worsening over time. Episodes had recently become more frequent and of concern. She had difficulty quantifying the severity of her pains, but admitted that at times it could be 10/10. She described morning stiffness >1 hour, which was aggravated by rest, but ameliorated by activity, and joints that were red, swollen, warm, and painful. The pattern of joint involvement was initially asymmetrical, involving some of the small joints of her hands (PIPs and MCPs); however, progressed to involve most of the small joints of her hands, metatarsal phalanges, and knees, in a peripheral symmetrical polyarticular pattern. She had also complained of shoulder and neck stiffness in the past, and difficulties in closing her jaw. She had seen a dentist in the past concerning the later, and Valium had been prescribed. Unfortunately, it was only helpful for the first five days. Furthermore, she denied any back pain or spine involvement.

On review of systems, she admitted to profound fatigue, mild weight loss, poor appetite and sleep, but denied any fevers, chills or myalgias, as well as any neurological, cardio-respiratory, GI or GU symptoms. She denied any infections over the past year. Her mood has been fluctuant, and she describes frustration, and frequent episodes of anxiety. However she did not have any other features of a psychiatric disorder, such as Major Depressive Disorder.

Mrs. TT was born in Bangladesh, and has not traveled for over 10 years. She is a very active individual, who enjoys skiing with her daughters. Recently, she has had difficulties participating in many of her favored past-times due to a decrease in her exercise tolerance. She has had fine and gross motor difficulties, which are most prominent in the mornings, with difficulties in dressing, griping, and getting out of bed. On numerous occasions, she is unable to commute to work or carry out duties of her occupation which involve typing. Her functional capacity classification at times is of Class III: marked restriction; can’t perform activities of usual occupation/self-care.

Mrs. TT has a previous history of eczema. Her past history is not significant for any trauma or abuse. She has had a tonsillectomy and left knee arthroscopy secondary to a left knee injury in the past. She denies any alcohol or tobacco use. Her family history was positive for severe rheumatoid arthritis in her maternal grandmother and paternal grandfather. No other diseases were positive in her family history. The patient denies any allergies. She is not on any medications currently; however she has been taking Tylenol, two to six tablets a day with moderate relief of her pain.

Physcial Examination

Mrs. TT is an anxious, thin, middle aged, oriental female that appears her stated age. She was alert and oriented, and was in no apparent distress. There were no stigmata of anemia or liver disease.

Vitals were BP 120/75 (R and L), HR 72, and weight 57 kg (screening for possible signs of a systemic process or internal organ involvement other than the joints). Head and neck examination was normal. There was no alopecia, ocular inflammation (clear fundi), oral or nasal ulcerations/bleeding, malar rash or telangectasia on inspection. There was absent lymphadenopathy and a normal thyroid. Chest was clear, with bilateral and equal air entry (no interstitial disease or effusions). There were no murmurs, rubs or bruits. Examination of the skin and nails did not reveal any psoriasis, rashes, periungual erythema, livedo reticularis, ulcerations, erythema nodosum or telangiectasia. There was a tiny nodule on her left elbow. Examination of her neurological system revealed no signs of any neuropathy or of any CNS abnormalities. The patient had good bulk and strength of her small hand and foot muscles, in addition to her neck, shoulders, hips and knees. She did have difficulty with dorsiflexion of her toes bilaterally. Reflexes were all 2+ and symmetrical and plantar responses were normal bilaterally. Vibration thresholds were 0.2 microns on median and ulnar innervated fingers bilaterally and 0.5 microns on the toes. The patient had normal coordination, and tandem gait.

MSK examination revealed a normal axial skeleton. She had normal posture and alignment, with no muscle spam or bony or soft tissue tenderness. Range of motion (ROM) of her back was normal. Special tests for inflammatory back pain were normal, including occiput-to-wall distance, forward finger-to-floor distance, chest expansion, and a Schobers test. Mechanical back pain tests were also negative, such as straight leg raises, and a femoral stretch test. Examination of the neck, shoulders and hips were also normal. Knee examination revealed some joint line tenderness. The rest of the examination was normal. Examination of peripheral joints revealed erythema, and swelling, with warmth, joint line tenderness, and palpable joint effusions and reduced ROM (both active and passive) in her MCPs and PIPs, MTPs and dorsum of her foot bilaterally. These were much more pronounced on her left side. There was no muscle atrophy, deformities, crepitus or joint laxity found. Furthermore, she did not have any trigger points, 0/14 (eg, fibromyalgia).

References:

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2. Lubeck DP. Patient-reported outcomes and their role in the assessment of rheumatoid arthritis. Pharmacoeconomics 2004, 22; Suppl. 1: 27-38.

3. Anonymous. The burden of rheumatoid arthritis. Based on a presentation by Fredrick Wolfe, MD. Am J Manag Care 1999, 5; Suppl. 14: S852-9; discussion S866-9.