The Patient with Rheumatoid Arthritis

Abstract

A 56-year-old woman who had suffered from severe progressive rheumatoid arthritis for ten years was scheduled for elective replacement of a severely degenerated right hip. Medical history was positive for hypertension, dysphagia, and occasional tingling of the hands on excessive neck movement. Medications included prazosin 2mg q.d., hydrochlorothiazide 50mg q.d., prednisone 10mg q.d., and a six-month course of gold.

Laboratory results indicated the following: hemoglobin 11gm/dl; hematocrit 31%; electrolyte levels within normal limits; BUN/CR, 17/1.1; urinalysis, normal; chest x-ray: diffuse haziness but no acute infiltrate, no cardiomegaly; cervical spine x-ray: atlantoaxial subluxation, subaxial subluxation C4-5; ECG: no acute changes, normal sinus rhythm, left ventricular hypertrophy; arterial blood gas analysis on room air: pH, 7.42; CO₂, 38mmHg; O₂, 72mmHg; saturation, 93%. On physical examination vital signs were BP 160/96mmHg, pulse 86/min, respiration 22/min, temperature 36.8°C; weight was 74kg, height 5′4″.

Airway assessment revealed mouth opening 3cm, reduced neck mobility in all directions, leftward laryngeal deviation, flexion deformity of neck. Chest: breath sounds clear but diminished in all fields, heart tones regular and without murmurs. Extremities: hands with marked bilateral deformities and ulnar drift, rheumatoid nodules over both elbows, swelling and tenderness of wrists, elbows, and knees. Hips showed reduced mobility, right greater than left.