Case Discussion

Pain in rheumatic disease

Dr.B.P.Putra Suryana SpPD-KR
Rheumatology, Internal Medicine
Brawijaya University Dr.Saiful Anwar Hospital Malang

Case 1
Female, age 58, obese
History : right knee pain since the last 5 weeks.
History of recurrent knee pain for 3 years.
Treatment history: ibuprofen, piroxicam,
diclofenac, glucosamine.
Examination : joint swelling on right knee,
warmth, sign of joint effusion and crepitation
on both knee.
Laboratory : ESR 25 mm, CRP negative, RF
negative, uric acid 7.5 mg/dL

Question 1
What is the diagnosis for right knee pain?
A. Knee osteoarthritis
B. Rheumatoid knee
C. Gouty arthritis
D. Septic arthritis
E. Ankylosing spondylitis

Recent treatment :
natrium diclofenac
3x50 mg daily,
tramadol 2x50 mg,
glucosamine capsul
500 mg daily.
Response to
treatment :
persistent knee pain,
very minimal
response to the
treatment

Question 2
What are the treatment option?
A. Continue NSAID, add opioid analgetic
B. Change NSAID, continue glucosamine
C. Change NSAID to celecoxib
D. Intraarticular steroid
E. Arthroscopic joint lavage

Question 3
What most likely cause the persistent knee
pain in this OA patient?
A. The osteophytes
B. The joint space narrowing
C. The crepitation
D. Sclerosis subchondral
E. Joint inflammation induced by intraarticular fragment

Case 2
Female, age 53, a teacher.
History : joint stiffness last until mid-day, joint pain on
almost the joints, joint swelling on hands, wrist, and
knees. Having the complains for years. Mild fever,
malaise. History of hematemesis with ulcer on
endoscopy.

Examination : joint
tenderness and joint
swelling on MCPs,
PIPs, wrists, elbows
and both knees

Question 4
What is the diagnosis?
A. Possible rheumatoid arthritis
B. Rheumatoid arthritis
C. Generalized osteoarthritis
D. Gouty arthritis
E. Not known, diagnosis must be
confirmed by laboratory test (RF, ESR and
CRP)

Question 5
What do you suggest to treat the pain?
A. Acetaminophen 3x1 gram
B. Increased methyl-prednisolon 3x8 mg
C. Continue diclofenac 3x50mg with
omeprazole 20 mg daily
D. Combined diclofenac and meloxicam
E. Stop NSAID and start with celecoxib 2x200 mg

Case 3
A 35-year-old male
History : complains chronic back pain
for more than 5 years. Radicular pain
from back to lower limbs. Was
considered as muscle cramps,
osteoporosis, mechanical back pain.
Took many kind of NSAIDs with
minimal and temporary responses.
Examination : Arthralgia on hand joint,
knee, and buttock pain. No clear joint
swelling

Scober test
showing limited
movement of spine,
especially spine
flexion

Sakroiliitis pada Ankylosing

spondylitis

X-ray

Bone scan

Question 6
What is the most possible diagnosis?
A. Gouty arthritis
B. Rheumatoid arthritis
C. Spondyloarthropathy
D. Ankylosing spondylitis
E. Spondylosis

Question 7
What do you suggest for treatment?
A. NSAID or Celecoxib
B. Pregabalin
C. Methyl-prednisolon
D. DMARDs (metotrexate, sulfasalazine)
E. Combine all above

 Terima kasih
Semoga bermanfaat

RSU Dr.Saiful Anwar

Jalan JA Suprpato No.2 Malang