Thank you for referring this 42-year-old lady, Zoe Adams, who works as a high school teacher. She is a non-smoker and drinks alcohol socially (2-3 glasses of wine per week). Family history significant for rheumatoid arthritis in her mother and osteoarthritis in her father.
Summary:
Zoe presents with a 6-month history of progressive joint pain and stiffness, primarily affecting her hands, wrists, and knees. Morning stiffness lasts approximately 2 hours. She reports fatigue and occasional low-grade fever. Previous treatment with over-the-counter NSAIDs provided minimal relief. Symptoms have begun to interfere with her daily activities and work performance.
Examination reveals bilateral swelling and tenderness of the MCP and PIP joints of both hands. Wrists show reduced range of motion and synovial thickening. Knees demonstrate mild effusion bilaterally. No rheumatoid nodules observed. Cardiovascular and respiratory examinations unremarkable.
Investigations:
15/05/2023: Blood tests show elevated inflammatory markers: CRP 28 mg/L, ESR 40 mm/hr. RF positive at 75 IU/mL, anti-CCP antibodies strongly positive at 120 U/mL. CBC reveals mild anemia with Hb 11.2 g/dL. Liver and kidney function tests within normal limits.
22/05/2023: X-rays of hands and wrists demonstrate early erosive changes in MCP joints bilaterally, consistent with early rheumatoid arthritis.
Management:
Working diagnosis is rheumatoid arthritis based on clinical presentation, positive serology, and radiographic findings. Differential diagnoses include psoriatic arthritis and systemic lupus erythematosus, but less likely given the absence of skin involvement and negative ANA.
Initiating treatment with methotrexate 15 mg weekly, folic acid 5 mg daily (except on methotrexate day), and prednisolone 10 mg daily for 4 weeks, tapering by 2.5 mg every 2 weeks. Advised on potential side effects and importance of regular monitoring. Educated patient on RA course and importance of early aggressive treatment.
Follow-up in 6 weeks to assess treatment response, monitor for side effects, and consider addition of hydroxychloroquine if inadequate improvement. Will repeat blood tests including CBC, liver function, and inflammatory markers prior to next visit.
