Question

A 28-year-old legal assistant presents to her GP after being bothered by stiffness in the joints of both of her hands for the past few weeks. The stiffness is most prominent on awakening and lasts approximately an hour before getting better through the day. She denies any other musculoskeletal problems or any other joints being affected. Her only medical history is mild asthma. Her family history is positive for type 1 diabetes in her brother.

Examination
Physical examination reveals a well-looking, slim woman. Her metacarpophalangeal joints
are slightly swollen bilaterally and mildly tender, and there is some pain on palpation over a
few of the interphalangeal joints in both hands. Metacarpal squeeze test is positive bilaterally.
Questions
1. Based on the history and examination findings, suggest a differential diagnosis.
Which diagnosis is most likely and why?
2. What further investigations are required, and which tests are most predictive for the
likely diagnosis?
3. Summarize the pathophysiology of the underlying diagnosis. What extra-articular
complications may arise with this condition?

Answer 1

1. Base on the history and examination findings the patient is having the diagnosis of Arthritis.

The patient is having the complaints of stiffness in the joints of both of her hands for the past few weeks. The stiffness is most prominent on awakening and lasts approximately an hour before getting better through the day. She dont have any other associated muskulo skeletal problems also. On physical examination Her metacarpophalangeal joints
are slightly swollen bilaterally and mildly tender, and there is some pain on palpation over a few of the interphalangeal joints in both hands. Metacarpal squeeze test is positive bilaterally. All these symptoms are the common clinical manifestations of rheumatoid arthritis.

2. For the diagnosis of Rheumatoid arthritis, apart from physical examination, additional investigations such as X-rays of the joints,MRI of joints, ultrasounds to identify the quality of synovial and other joints, arthroscopy, Blood investigations such as Rheumatoid Arthritis factor, ANA profile, and anti CCP, ESR, CRP are carried out. ACR criteria also commonly used for the diagnosis.

3. Pathophysiology of arthritis

Arthritis is most of the time, an auto immune disease.Where the individuals immune sysytem, attack the lining the joints capsule. This leads to inflammation of the synovial joint. This will eventually destroy the cartilage and bone of the underlying joint.The disease usually progress into 3 stages. They include intiation phase due to inflammation, amplification stage due to T-cell activation leads to auto antobody production in the body leads to  chronic inflammatory phase with tissue injury resulting from cytokines.

the possible complications include,

• Osteoporosis
• Rheumatoid nodules over the joints
• improper body allignments
• unable to get up from bed
• bedridden
• infections