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Abstract: Rheumatoid arthritis is a symmetric, inflammatory peripheral polyarthritis of unknown etiology. It usually leads to joint deformities due to tendon and ligament stretching and joint destruction due to cartilage and bone invasion. In this case, the patient had bilateral wrist arthralgia for more than 40 years and was admitted to the hospital for 1 day of aggravation. The patient was immediately given surgery and medication, and the patient’s prognosis was good.
[Basic information] Male, 63 years old
Disease Type】Rheumatoid arthritis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of consultation】January 2019
Treatment plan】Surgical treatment (osteotomy correction) + medication (clofenamic acid tablets, ibuprofen extended-release capsules, prednisone acetate tablets, ceftriaxone sodium for injection, streptomycin sulfate for injection, methotrexate tablets, cyclosporine soft capsules)
Treatment period】30 days of inpatient treatment, 3 months of outpatient follow-up
Effectiveness】The patient was discharged from the hospital after the surgery went well and there were no other complications.
I. Initial interview
Patient, male, 63 years old. The patient was diagnosed with “rheumatoid arthritis” more than 40 years ago. Today, he has pain in the metacarpophalangeal joints, interphalangeal joints and bilateral wrist joints of both hands with no obvious reason, accompanied by joint swelling and limitation of movement, and morning stiffness, which lasts about 1 hour. The patient’s temperature was normal, and he was treated with dexamethasone acetate 5mg orally and ibuprofen extended-release capsules, which relieved the pain. Physical examination: deformity of both hands, swan-neck deformity of the left ring finger, swelling of both wrist and elbow joints, normal muscle strength and tone of the limbs, normal joint mobility, no edema in the lower limbs, no varicose veins. Pain, temperature and touch sensation were normal, there was no muscle atrophy, no paresis and no ataxia. Babinski’s sign and meningeal stimulation sign were negative bilaterally. The patient was given digital radiographs, which showed narrowing of the joint space of both wrists, the joint surfaces were still smooth, and small capsular changes were seen under the interphalangeal joint surfaces of both thumbs, and the joints were mildly deformed. The preliminary diagnosis was “rheumatoid arthritis”.
II. Treatment history
As the patient was in the inflammatory phase, after communication with the patient and his family, he was given clofenamic acid tablets, ibuprofen extended-release capsules and prednisone acetate tablets to control his symptoms. Three days after admission, the patient’s acute phase was basically controlled by medication, the systemic symptoms were more stable, the patient’s joint swelling was relieved, and the patient was given “osteotomy correction”. The patient was given injectable ceftriaxone sodium and injectable streptomycin sulfate to prevent infection, and microwave therapy was given to promote wound healing. The patient was encouraged to start active and assisted active finger and forearm exercises immediately after surgery to reduce swollen finger movements and active limb lifting exercises. In addition, the patient was given immunosuppressive drugs, methotrexate tablets and cyclosporine soft capsules.
III. Treatment effect
The patient’s symptoms of the affected limb improved after surgery and medication treatment, and her diet, sleep and bowel movements were normal. The patient’s wounds healed well 14 days after surgery and the plaster splint was removed. At 28 days postoperatively, the patient recovered the mobility of the affected limb well and gradually removed the fixed brace. There was no fever on examination and no postoperative infection. At the request of the patient and his family, he was discharged from the hospital. The patient’s symptoms such as joint swelling, pain and morning stiffness were significantly relieved at the time of admission, and there was no other significant discomfort.
IV. Precautions
The patient was discharged after her condition improved, and I was sincerely happy for her. The patient was advised to continue rehabilitation training after discharge and to continue using medication as prescribed by the doctor. Patients with acute attacks of joint swelling and pain, fever and systemic symptoms should take care of bed rest. Activities can be gradually increased to avoid prolonged bed rest leading to joint disuse and muscle atrophy. Daily attention should be paid to adequate protein and various vitamins in the diet. Eat more protein- and vitamin-rich foods, such as fish, eggs, apples, etc. Avoid spicy and stimulating foods, such as pepper. Pay attention to quit smoking and alcohol after discharge from the hospital. Pay attention to keeping warm and avoiding colds on a daily basis.
V. Personal insight
The onset of rheumatoid arthritis is acute, but the course of the disease is short, an attack can be asymptomatic for months or years, and then recur after a period of quiescence. In patients with insidious attacks, the course of the disease progresses slowly and can last for several years, during which alternating remissions and relapses are characteristic of rheumatoid arthritis. In some patients, remission is complete after each attack, but after each attack the diseased joint becomes more stiff and inflexible, and the symptoms become more severe, eventually fixing the joint in an abnormal position and forming a deformity. For example, in this case, the patient had to undergo surgery to relieve symptoms due to recurrent attacks of rheumatoid arthritis for more than 40 years, and the symptoms gradually worsened, resulting in a severe deformity of the hand.