Dan Druff is a 54 year old man who has presented with pain in his wrists. It has been painful for around a year and a half, but has put off doing anything about it until now. He states he has also felt more tired, particularly in the morning, and due to his illness he has been struggling with his job. The pain in his wrists has moved to his hands, fingers and elbows. The pain is worst later in the day. He has a past medical history of depression, and takes sertraline 50mg once daily.
On examination, he looks well. His blood pressure is 142/71 mmHg, heart rate 15 breaths per minute, apyrexial. His chest sounds clear, whilst his abdomen is soft, non tender. On joint examination, he has proximal interphalangeal, metacarpophalangeal and wrist tenderness on palpation, which is bilateral. Schober's test is normal. Power is 5/5 throughout all four limbs. Skin examination is normal.
This is a presentation of fatigue and joint pain. The examination demonstrates symmetrical joint pain. There is raised Rh factor and anti-CCP. The rest of the conditions may be ruled out by lack of evidence: there is no suggestion of Ankylosing spondylitis, autoantibodies are only raised for ANA, uric acid is not raised and chest X ray is normal. The most logical cause of this presentation is rheumatoid arthritis.
