(Disclaimer: This article is for scientific use only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: The patient in this case is a 55-year-old aunt who had joint pain a year ago, but did not undergo relevant examination and treatment at that time until the pain became severe on a daily basis, and only then did she visit our outpatient clinic, where she was diagnosed with rheumatoid arthritis after relevant examinations. According to the patient’s comprehensive situation, some medications suitable for her were prescribed, and after 1 week of hospitalization, her discomfort was reduced and her condition was controlled.
Basic information】Female, 55 years old
Disease Type】Rheumatoid arthritis
Hospital】The First Hospital of China Medical University
Date of consultation】September 2021
Treatment plan】Oral medication (hydroxychloroquine sulfate tablets, prednisone acetate tablets, calcium carbonate D3 tablets, alfa osteoporosis tablets)
Treatment Period】7 days of hospitalization, followed by intermittent medication
Effectiveness】Improvement and reduction of joint pain
I. Initial consultation
The patient is a 55-year-old female, who has been suffering from joint pain of the extremities for the past one year without any obvious cause, including wrist, metacarpal, proximal interphalangeal, elbow, shoulder and knee joints. The patient came to the hospital today for further treatment because the pain and other symptoms were affecting his daily life, and on physical examination at the outpatient clinic, the proximal interphalangeal joints of both hands, both wrists and both elbows were mildly painful, and the activity was mildly restricted.
II. Treatment process
After communicating with the patient and his family, he completed X-ray, routine blood tests and other related tests, which indicated that the blood sedimentation of 91 mm/h, anti-CCP antibody of 1266.82 RU/ml, rheumatoid factor of 70.6 IU/ml and immunoglobulin G of 27.15 g/L were all higher than normal; X-ray diagnosis indicated that the lesion did not involve the left wrist joint and left elbow joint for the time being. The diagnosis of rheumatoid arthritis was clear. The patient was treated with medications, including hydroxychloroquine sulfate tablets to regulate immunity, prednisone acetate tablets for anti-inflammation and pain relief and immune suppression, and calcium carbonate D3 tablets and alfacalcidol tablets for calcium supplementation and bone protection. At the same time, the patient’s condition was closely monitored, especially the degree of joint pain.
III. Treatment effect
After 7 days of hospitalization, the pain and swelling of the joints of the extremities were reduced, the proximal interphalangeal joints of both hands, both wrist joints and both elbow joints were mildly painful, and the movement was mildly restricted. Half a month later, the patient was rechecked according to the doctor’s prescription. The movement of all joints was normal, indicating that the disease had been controlled.
IV. Precautions
After the patient’s condition had improved to a certain extent, I agreed to discharge him under the comprehensive assessment, and the patient was very happy and I felt very relieved. I also instructed the patient to keep taking hydroxychloroquine sulfate tablets, prednisone acetate tablets, calcium carbonate D3 tablets, and alfacalcidol tablets after discharge, and to come back to the hospital half a month later for follow-up. Finally, the process of taking medication can be combined with the daily exercise of moving joints, such as lifting hands, lifting legs, bending knees, etc., to maintain joint function.
V. Personal insight
The patient in this article did not have her wrist, elbow, shoulder and foot joints examined and treated at the first time, which caused her to suffer from pain for more than one year, but fortunately, she did not have joint deformity or joint cartilage destruction, and the treatment was not too late to start and her condition was controlled. Therefore, it is important to diagnose and treat joint pain early when it occurs throughout the body, and not to delay treatment.