UNIVERSITAS INDONESIA

RHEUMATOID ARTHRITIS

CASE PRESENTATION

ADLY NANDA AL FATTAH, 0606065125 DINI

Supervisor:

INTERNAL MEDICINE FACULTY OF MEDICINE UNIVERSITAS INDONESIA JANUARY 2011

CHAPTER 1 Case Illustration

Identity Name Age Address Religion Occupation : Mrs. A : 35 years old : Rangkasbitung, West Java : Moslem : midwife

Anamnesis (autoanamnesis 28th December 2010) Chief Complaint Pain and swollen on her shoulder, elbow, wrist, finger, knee, and ankle joints since 2 years before hospital admission. Present History Illness Since approximately 2 years ago (beginning of 2009), patient complaints morning stiffness on her shoulder, elbow, wrist, finger, knee, and ankle joint. The complaint was appear almost every day and persisted for about an hour. Patient also complaints that she had her proximal part of the right index finger, the joint of the right little finger, and the left knee swelling, redness, and tense. There was also pain on those joints. The pain is persisted, not moving to the other joints. Patient tells that she was not being able in wearing her own trouser and holding the comb. The patient went to the internist at Rangkasbitung and underwent several laboratory tests. The results are the positive rheumatoid factor (RF), 105 mm of erythrocyte sedimentation rate (ESR), and normal limit of uric acid. Patient given Methylprednisolone 3 x 4 mg for 2 months and then the complaints was subsided. Patient also received Meloxicam 2x7.5 mg, Ranitidine 2 x 1 tab, CaCO3 2x1 tab. At that time (19 months ago), the patient is being pregnant. After delivery, the patient wants to continue to check-up at RSCM regarding the internist opinion. Even though the complaints were being subsided on the therapy given, she still wants to find better therapy at rheumatologist at RSCM. At this time, patient is coming to the clinic to check up for her disease (for previous 10 months, the patient also checked up at RSCM regularly). The patient is still complaining of pain on her left knee, both of wrists, and left little finger joints. The pain is persisted and felt especially on the movement of the joint. The drugs taken regularly are Methotrexate 6 tablets for 1 week, Methylprednisolone 2 x 1 tablet, folic acid 2 x 1 tab, CaCO3 3x1 tablet, Lansoperazole 1x1 tablet, Actonel 2x20 mg/week. There was no history

of nausea, vomiting, diarrhea, mouth sores and hair loss. Now the patient is being able to drive the motorcycle, but the pain is still felt when she is walking. Past History Illness She denied any history of hypertension, DM, asthma, and allergy Family History Illness There is history of hypertension from the mother. She denied any history of DM, asthma, allergy, and heart disease in her family. There are no histories of rheumatoid arthritis or the other joint diseases in the family. Physical Examination General status: CM, moderately Ill Vital signs: Blood Pressure 100/70 mmHg Heart Rate 88x/min, regular, enough filling Temperature 36,6oC Respiratory Rate 16 x/min

Body Height: 152 cm Body Weight: 57 kg BMI : 24.6

Status Generalis Head Eye : : Normocephali Anemic conjunctival (-/). Icteric sclera (-/-). Direct Pupils Reflexes +/+, Indirect Pupils Reflects +/+ deformity -, wide, secrete -/-, secrete -/-, septum deviation -/-, conchae hypertrophy -/Tonsil T1/T1, hiperemis (-) good mucosal, bad oral hygiene, caries dentis (+) JVP 5-2cmH20, trachea is in the middle, lymph nodes not palpable, thyroid is not palpable

Ear Nose

: :

Throat : Mouth : Neck :

Thorax:

Lung I P P A Heart I P P line A Abd Ext wrist.

: : Statically and dynamically symmetric : Symmetric left and right fremitus : Sonor above all lung field :vesicular, rhonchi (-/-), wheezing (-/-) : : Ictus cordis is not visualized : Ictus cordis is palpable on 1 finger medial from left midclavicular line : Right border : Right parasternalis linne, Left border: 1 finger medial from left mudclavicular

: Normal heart sound S1 & S2, murmur (-), Gallop (-) :flat, supple, ascites (-), pain (-), bowel sound (+) normal :Oedema (-), warm acral, CRT < 2, swollen on left knee, right proximal interphalanges, and left

Local Status (28/12/2010)

Local Status (24/1/2010)

Laboratory Findings (27/12/2010) Items Hemoglobin Hematocryte Leukocyte Diff. count Basophiles Eosinophile Neutrophile Lymphocytes Monocyte Thrombocyte Erythrocyte Sedimentation Rate SGOT (AST) SGPT (ALT) Anti CCP serum Problems list: Rheumatoid Arthritis Plan Diagnostic Plan: - CBC, ALT/AST, Ureum/Creatinine Treatment Plan: Oral Methotrexate 1x15 mg/week 7 tablets once weekly Oral Methylprednisolone 1x4 mg/day Folic acid 2 x 1 tablet/day CaCO3 3 x 1 tablet/day Lansoperazole 1 x 30 mg /day Patient 13.6 g/dl 42.7 % (35-43) 15.800/uL 0 % 0 % 90 % 9 % 1 % 428.000/ul 27 mm 14 12 2066.5 RU/ml Normal limit 13-16 40-48 5000-10000 0-1 1-3 52-76 20-40 2-8 150.000-440.000 0-10 < 33 < 46

Education Plan: Exercise: regular, dynamic physical activity Weight Control: weight control and dietary modification Disease monitoring and co morbidities : o o o o eating plenty of fruit, vegetables and whole grain cereal foods eating foods rich in fish oil (omega-3) eating a diet low in fat eating only a moderate amount of sugars and foods containing added sugars, and

o o o

choosing low salt foods and using salt sparingly Monitor at least 3 times per year: CVS, GIT, liver, and renal function

Inform about the side effects of the drugs; Use contraception to prevent pregnancy for until 3 months stop taking methotrexate

CHAPTER 2 LITERATURE REVIEW

REFERENCES