41M with chest pain and polyarthralgia
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This history is of a 41 M, bus cleaner by occupation, which dates back to February when he came to our hospital with complaints of loss of appetite, dyspnea, fatigue which was present since 6 months I.e., since August.Patient was apparently asymptomatic before August of 2019 when he first started feeling weak and out of breath while doing his daily activities which hindered his routine, making him unable to do his work like he used to do. He also has lost weight of approximately 3-4 kgs which was known from loosening of his dresses since 4 months. There is history of fever 2 months after he started loosing weight .He also complained of body pains since 1 week prior to presentation and also fever, polyarthralgia and dry cough since 4 days He came to casualty with history of fever of low grade with chills and rigors which is intermittent type with no clinical variation since 4 days before presentation with 2 episodes of fall preceded by giddiness on the day of presentation.He had polyarthralgia involving B/L knee joint, small joints of hand and foot, ankle, wrist. After that his fever reduced but body pains reduced only by about half compared to his initial presentation and patient was discharged. Till 15 days back he doesn't record any new onset of symptoms. Now he came to the opd with complaints of cough since15 days which is productive with whitish sputum, and no diurnal variation, and is associated with cold. He also complains of chest pain since a day, non radiating, squeezing type. No aggravating or relieving factors.patient gives no history of headache, blurring of vision, excessive sweating, palpitations, shortness of breath, syncopal attacks, no awakening from sleep to take lungful of air. He still have joint pains involving bilateral shoulder and small joints of foot and hand with early morning stiffness. There is joint space tenderness. Patient is an alcoholic for about 6 years and stopped drinking 3 years back.
At the time of presentation:
Patient is afebrile, Bp-100/60 mm Hg, PR-112 bpm, RR-20 cpm.
Patient has pallor, no icterus ,clubbing, cyanosis,lymphadenopathy,edema
Cvs:S1,S2 heard, Loud S1, tachycardia present, no murmurs
Rs:BAE+, NVBS
Musculoskeletal system:
Joint space tenderness of ankle wrist and small joints of hands and feet.
There was both Active and Passive Limitation of Joint Movements with restricted range of movements (ROMs)
There is ulnar deviation of the fingers and radial deviation of the metacarpals bones.
There is piano key deformity of distal radioulnar joint.(Piano key deformity is due to subluxation of the distal radio ulnar joint)
CRP-Positive
RA factor-negative
ECG-showing PR segment depression
The ACR/EULAR classification system is a score-based algorithm for RA that incorporates the following 4 factors:
Joint involvement
Serology test results
Acute-phase reactant test results
Patient self-reporting of the duration of signs and symptoms
1 large joint (ie, shoulders, elbows, hips, knees, ankles) = 0 points
2-10 large joints = 1 point
1-3 small joints (with or without involvement of large joints), such as MCP, PIP, second to fifth MTP, thumb interphalangeal (IP), and wrist joints = 2 points
4-10 small joints (with or without involvement of large joints) = 3 points
More than 10 joints (at least 1 small joint, plus any combination of large and additional small joints or joints such as the temporomandibular, acromioclavicular, or sternoclavicular) = 5 points
At least 1 serology test result is needed for RA classification. Points are allocated as follows:
Negative rheumatoid factor (RF) and negative anti−citrullinated protein antibody (ACPA; in the ACR/EULAR criteria set, tested as anti−cyclic citrullinated peptide [anti-CCP]) = 0 points
Low-positive RF or low-positive ACPA = 2 points
High-positive RF or high-positive ACPA = 3 points
Normal C-reactive protein (CRP) and normal erythrocyte sedimentation rate (ESR) = 0 points
Abnormal CRP or abnormal ESR = 1 point
Shorter than 6 weeks = 0 points
6 weeks or longer = 1 point
