R H E U M AT O I D

ARTHRITIS
I N T E R N A L M E D I C I N E D E P A R T M E N T – R H E U M AT O L O G Y

Sitti Fatimah M.Halik C014182109

A.Dhidit Dwi Putra C014182012
Mukti Mukhtar C11115036
PATIENT IDENTITY
Name : Mrs. N
Age : 38 years old
Date of Birth : 01 – 11 – 1981
Religion : Muslim
Address : Bara-baraka
Hospital : Wahidin Sudirohusodo Hospital
MR : 11.79.04
Date of entry : April, 23rd 2019
HISTORY TAKING
Chief complaint : Pain and stiffness at both of her knee
joints
Present history :
Mrs. N came to the rheumatology policlinic in RSWS with the chief
complaint is pain at both knee joint. Pain at both of her knee joints
felt since last 20 years. The pain is continuous. The patient can not
walk because of the pain. Stiffness occurred especially in the
morning approximately for more than 1 hours.
HISTORY TAKING

 The pain occurred firstly at her toes, and later occurred at her
fingers since last 20 years. Patients also feel pain and stiffness
at her toes and fingers. Stiffness followed by pain in the joints.
The stiffness also occurred especially in the morning
approximately for more than 1 hours. Pain in the other joints like
elbow and shoulders joints aren’t occurred.
 There is no cephalgia, malaise, cough without mucus, lost of
appetite. Defecation and urination are normal. No history of black
stool. No history of DM and Hypertension. There is history of
taking medicine. There is no family history with the same
complain.
PHYSICAL EXAMINATION
 General description : Moderate illness
 Weight : 55 kg
 Height : 155 cm
 Body Mass Index : 22,89 kg/m2
 Nutrition : Normal

 Vital signs
 Blood pressure : 130/90 mmHg
 Heart rate : 78 x/minutes
 Respiratory rate : 20 x/minutes
 Temperature : 360C, axilla
 VAS : 5 / 10
 PHYSICAL EXAMINATION
 Heart
 Inspection : Ictus cordis is invisible
 Palpation : thrill (-)
 Percussion : normal
Right heart border in ICS IV linea parasternalis dextra,
Left heart border in ICS V linea medioclavicularis sinistra
 Auscultation : Heart sound I / II, regular. No gallop , no murmur
 Abdomen
 Inspection : convex
 Auscultation : Peristaltic (+), normal.
 Palpation : Liver and spleen are not palpable
 Perkusi : Tympani (+)
 RHEUMATOLOGY STATUS
Gait : Unable to walk
Arm : Tenderness (+) at phalanges, rubor (-), and
limited ROM (+). Swelling (+). Swan neck deformity (+)
Legs : Tenderness (+) at phalanges and knees bilateral, rubor (-),
calor (-), tumor (-), crepitation (-), effusion (+), deformity (-),
oedem (+) at both knee joints and limited ROM (+) at
phalanges and knee bilateral.
Spine : Normal
LABORATORY FINDINGS
FROM RS WAHIDIN SUDIROHUSUDO (23.04.2019)
Result Reference Unit
WBC 10.9 4.00-10.00 10^3 U/L
HGB 11.2 14.00-18.00 g/dL
MCV 86 80.0-100.0 µm3
MCH 26 27.0-32.0 Pg
MCHC 31 32-36 g/dL
PLT 302 150-400 10^3 u/L
RBC 4.24 3.5-5.8 10^6 u/L
GDS 88 140 Mg/dL
Ureum 29 10-50 Mg/dL
Creatinin 0.50 <1.3 Mg/dL
SGOT 28 <38 U/L
SGPT 24 <41 U/L
LED I/II 55/90 P <20 L<15 mm/jam
Immunoserology Result
RF 6.9 IU/ml
 PROBLEM LIST

no Problems Planning diagnostic Planning therapy

1. Rheumatoid arthritis • Methotrexate

Based on: 7,5mg/week/oral
ACR Criteria • Metilprednisolon
a. Joint involvement >10 joints, 8mg/8 jam/oral
with 10 small joints and 1 • Meloxicam
large joint (5) 7,5mg/24jam/oral
b. Duration (> 6 weeks) (1) • Omeprazole
20mg/24jam/oral
Total score: 6 • Asam folat
DISCUSSION
 RHEUMATOID ARTHRITIS

• Chronic inflammatory disease of unknown etiology

marked by a symmetric, peripheral polyarthritis. It is
the most common form of chronic inflammatory
arthritis and often results in joint damage and
physical disability.
• RA is the common form of autoimmune arthritis.
• About 75% RA patients are women.
• Age of onset usually between 25-55 years

Kasper, DL. Fauci, AS. Hauser, SL. et.al. Harrison’s Principles of Internal Medicine. 19th Edition. McGraw-Hill. US: 2015.
From: Understanding the dynamics: pathways involved in the pathogenesis of rheumatoid arthritis
Rheumatology (Oxford). 2012;51(suppl_5):v3-v11. doi:10.1093/rheumatology/kes113
Rheumatology (Oxford) | © The Author 2012. Published by Oxford University Press on behalf of the British Society for
Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com
 Pathophysiology
Antigen –
Environmental agent, infectious agent

Genetic Activates CD4 helper

Susceptibility T cells and probably
HLA-DR4
HLA-DQ
B lymphocytes
HLA- DP
Cytokines

T cells stimulates
Activates
synovial macrophage
B lymphocytes
and fibroblast
Pathophysiology
T cells stimulates Activates B lymphocytes
synovial macrophage
and fibroblast
Formation of
rheumatoid
RANKL factor
Cytokines
Activates Formation of autoimmune
osteoclast complexes and probable
Fibroblast deposition in the joint
Chondrocytes
Synovial cells
Proliferation

Enzymes release Joint injury

(collagenase, streptomelysin, Pannus formation
elactase, PGE2 and matrix Joint destruction
metalloproteinases, others) Cartilage fibrosis
Ankylosis
CLINICAL MANIFESTATIONS

• Onset : slowly, symmetric arthritis

in weeks-month, often stiffness
occur in the morning during 1 hour
or more
• Tenderness
• Stiffness in many joints
• Synovial membrane inflamed
(synovitis)
• Deformity (boutonniere, swan
neck)
• Loss of function
• Ankylosis of bone, often at wrist or
ankle
DIAGNOSTIC CRITERIA

Aletaha D, Neogi T, Silman AJ, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League
Against Rheumatism collaborative initiative [published correction appears in Ann Rheum Dis. 2010;69(10):1892]. Ann Rheum Dis.
2010;69(9):1583.
 PILLARS OF RHEUMATOID ARTHRITIS
MANAGEMENT

1.Education
2.Exercise / rehabilitation
3.Pharmacologic medication
- DMARDs
- Biologic Agent
- Kortikosteroid
- NSAID
4. Surgery

Perhimpunan Reumatologi Indonesia. Diagnosis dan Pengelolaan Artritis Reumatoid. 2014

THERAPY RECOMMENDATION FOR RA

Perhimpunan Reumatologi Indonesia. Diagnosis dan Pengelolaan Artritis Reumatoid. 2014

 THERAPY RECOMMENDATION FOR RA

Perhimpunan Reumatologi Indonesia. Diagnosis dan Pengelolaan Artritis Reumatoid. 2014

 INSTRUMENT TO MEASURE DISEASE ACTIVITY:
DAS 28

Perhimpunan Reumatologi Indonesia. Diagnosis dan Pengelolaan Artritis Reumatoid. 2014

REMISSION CRITERIA

5 or more of the following requirements must be fulfilled for at least 2

consecutive months

• Morning stiffness < 15 minutes

• No fatigue
• No pain on joint
• No pain on joint by movement
• No soft tissue swelling in joint or tendon sheats
• ESR (Westergren method) : < 30 mm/hour (female)
< 20 mm/hour (male)
THANK YOU