case 7

She has had generalised rheumatoid arthritis for the past 10 years. Involved joints include hand and wrist joints, elbows, shoulders, knees, ankles and toes bilaterally together with the left hip joint. Five years ago she had a prosthetic hip replacement in the left side and her left ankle fused. Three years ago she had her right knee replaced too. She also has cervical spinal involvement, but with no neurological deficit.

She experiences joint stiffness in the morning, particularly in the hands, shoulders, neck and feet, which lasts about 2 hours and improves with activity. She is dependent in most activities of daily living but is able to feed herself. She usually cannot walk more than 50 metres due to joint and limb pain, and on such occasions she uses a wheelchair. Her daughter is her main carer.

She has been managed on variable doses of prednisone over the past 10 years, the maximum dose being 50 mg daily and the minimum 5 mg daily. She currently takes 7.5 mg prednisone daily. She has experienced multiple side effects associated with the chronic steroid treatment, including weight gain, acne, easy bruising, osteoporosis and diabetes mellitus.

She has also been treated with multiple other medications over the years, including diclofenac sodium, sulfasalazine and parenteral gold. Diclofenac therapy was stopped due to gastritis and sulfasalazine was stopped due to a rash. Gold therapy was stopped due to proteinuria. Currently she is managed on methotrexate 7.5 mg twice weekly together with celecoxib 200 mg twice daily. Both medications were commenced 8 months ago. She also takes folic acid 5 mg daily. She denies any known side effects associated with this treatment so far.

Her symptoms have never been completely controlled by any of the medications she has been treated with and she has experienced progressive deformity of both hands and feet over the years. The current level of control is the best she has ever achieved.

She denies any eye complaints, oral symptoms, vasculitic symptoms or sicca symptoms associated with her rheumatoid arthritis.

She was diagnosed with gastritis 8 years ago when she presented with epigastric pain. She denies any gastrointestinal bleeding, and the diagnosis of gastritis was established on gastroscopy. Subsequently the diclofenac therapy was stopped, and she was commenced on ranitidine 150 mg twice daily and has been symptom-free ever since. She does not know her Helicobacter pylori status and denies ever having been treated with the triple-therapy combination.

She was incidentally diagnosed with diabetes mellitus 6 years ago. She denied any symptoms of polyuria, polydipsia or weight loss on presentation. She was initially treated with dietary modifications and exercise alone. She was commenced on metformin 2 years ago. Currently she is managed on 500 mg metformin three times daily. She denies any side effects associated with this therapy. Her GP monitors her blood sugar level every 2 weeks and currently it averages around 6–10 mmol/L. She has seen an ophthalmologist on only one occasion, about 2 years ago. She was not diagnosed with any ocular complications. She denies any current ocular symptoms. She denies any known diabetic nephropathy. She has had proteinuria on only one occasion previously, which was attributed to the gold therapy. It resolved on stopping the drug. Her GP checks her urine every 6 months. She has never seen a podiatrist and denies any symptoms in her feet.

She denies ischaemic heart disease, stroke or calf claudication. She denies any neurological symptoms associated with diabetes.

She was diagnosed with osteoporosis 1 year ago when her rheumatologist ordered bone densitometry, but she denies any fractures. Her osteoporosis is treated with monthly pamidronate injections, which she has had for the past 6 months without any side effects. She also takes calcium carbonate 1500 mg daily together with calcitriol 0.5 mg twice daily.

She was diagnosed with chronic airflow limitation 1 year ago when she was investigated for progressive exertional dyspnoea. She is treated with salbutamol and ipratropium bromide via a metered dose inhaler two puffs twice daily. She was hospitalised for 3 days, 7 months ago, with infective exacerbation of chronic airflow limitation, which was treated with intravenous antibiotics.

Her current medications include prednisone, celecoxib, methotrexate, metformin, pamidronate, calcium carbonate, calcitriol, salbutamol and ipratropium bromide.

She gave up smoking 1 year ago, prior to which she had a smoking history of 20 pack-years. She consumes alcohol only very rarely, on social occasions.

She denies any known allergies.

She has been a divorcee for the past 15 years. She was married only once and has two adult daughters. She lives with her older daughter, who is 42 years old and is well. The second daughter is 38 years old, is married and lives separately but in the same city. She has two grandchildren. She has regular contact with her second daughter too. She is dependent on her daughter for assistance in all activities of daily living except feeding. She lives on the ground floor of a two-storey house. She has no steps to negotiate. Her house was modified previously under an occupational therapist’s recommendations to accommodate her needs. Her usual pastimes are watching television and listening to radio.

Her dietary history reveals adequate nutrition but no compliance with the diabetic diet.

She denies any sleep problems and she has never been depressed, despite her multiple significant medical problems.

Her family history is significant, in that her mother suffered from severe rheumatoid arthritis. She died at the age of 75 from an unknown cause. Her father died of an acute myocardial infarction at the age of 60. She has no brothers or sisters.

She worked as a clerk typist before retiring 20 years ago. She is on a disability pension, which is just adequate for her living. The daughter who lives with her is employed part-time as a nanny.

Her insight into her multiple medical problems seems satisfactory.

She had an intravenous cannula in the dorsum of her left hand and its insertion site was not inflamed. There were multiple ecchymoses in the dorsal aspect of her hands and forearm bilaterally.

She was using accessory muscles of inspiration and demonstrated pursed-lip breathing. Chest expansion was reduced in the upper and lower zones bilaterally and there was no dullness on percussion. Breath sounds were vesicular in the upper zone but there were crepitations in the mid- and lower zones bilaterally. Vocal resonance was not increased. The sputum mug contained yellow-green sputum.

Rheumatological examination showed bilateral symmetrical arthropathy of the hands and wrists with ulnar deviation at the metacarpophalangeal joints, ‘Z’ deformity of both thumbs, swan-neck deformity of the left index and right ring fingers and boutonnière deformity of the right middle finger. There was subluxation of the wrist joints bilaterally. There was wasting of the intrinsic musculature of the hands. These joints were oedematous but not tender or warm to touch. There was severe restriction of movement in all directions in the metacarpophalangeal joints, proximal interphalangeal joints and wrist joints bilaterally due to swelling, stiffness and deformity. Her hand power was severely restricted and functionality significantly compromised, with inability to unbutton, pick up a pen and write, or hold a cup.

There were non-tender, firm nodules of 2 cm diameter in the dorsal aspect of her elbows bilaterally.

There was tenderness in the anterior aspect of the left shoulder joint together with restriction of abduction to 60°, flexion to 90°, internal rotation and external rotation to 10° in each direction, bilaterally, due to stiffness.

There was tenderness over the C2, C3, C6 and C7 vertebrae, with severe restriction of neck flexion, extension and rotation.

There was tenderness over the temporomandibular joint bilaterally.

There was valgus deformity and medial joint line tenderness, together with crepitus on flexion, in the knee joints bilaterally. There was no Baker’s cyst.

There was hallux valgus deformity bilaterally in the feet with subluxation of all metatarsophalangeal joints. There was no tenderness or warmth to touch. Severe wasting of the intrinsic musculature of the feet was present.

Cardiovascular examination was unremarkable, with dual and normal heart sounds and the presence of all peripheral pulses.

Neurological examination showed a visual acuity of 6/24 with correction bilaterally. Fundoscopy showed multiple hard and soft exudates in the macular region bilaterally. The rest of the cranial nerve examination was unremarkable.

Upper limb examination showed profound weakness bilaterally in the intrinsic musculature of the hand and on shoulder abduction. Power was preserved at the other levels together with tone, reflexes, coordination and sensation.

Lower limb examination showed moderate proximal weakness with 3/5 power, bilaterally, on hip flexion, extension, abduction and adduction. Otherwise the lower limb neurological examination was unremarkable. The plantar response was flexor bilaterally.

She had difficulty with mobilisation due to weakness and a waddling gait.

Gastrointestinal examination was unremarkable. There was no organomegaly.

She had no lymphadenopathy.

Diabetic foot examination did not show any painful callosities, corns or ulcers.

In summary, this is a 65-year-old woman with severe rheumatoid arthritis presenting with a history of progressive dyspnoea and fevers on a background of diabetes mellitus, osteoporosis and chronic airway limitation. Her independence is severely compromised.

I have identified one acute problem and two main long-term problems that need addressing:

To address the issue of pulmonary disease, I would like to see: