CASE PRESENTATION

NAME :- Sharda Devi

AGE/SEX :- 45 yrs./ female
D.O.A :- 17-03-08
ADDRESS :- L-1/5, Police colony, Andrews
ganj, N.D
OCCUPATION :- Housewife

PRESENTING
COMPLAINTS
1. Pain and swelling in all joints of
body since 18-20 yrs.

2. Increased frequency of
micturition since 3-4 months.

HISTORY OF PRESENTING
COMPLAINTS
Patient was apparently well 20 yrs. Back when she
started complaining of pain and swelling in left
knee joint and then to right knee joint and then
gradually spread to all joints of body.
ONSET :- gradual.
LOCATION:- both knee jts., both ankle jts.,both
shoulder jts.,both elbow jts., both wrist jts.,
bilateral interphalangeal jts.
SENSATION:- Stiffness
MODALITIES:- < movement, cold weather,
morning
> hot fomentation

TREATMENT HISTORY
Taken allopathic treatment from safdarjung hospital for 3
weeks, also taken ayrvedic and homoeopathic
treatment with transient relief.
2. Increased frequency of micturition since 3-4 months.
ONSET :- gradual
FREQUENCY:- every 5-10 min during daytime,3-4 times
during night.
CHARACTER:- yellow, no burning, no other associated
complaint.
Sometimes there is uncontrollable urge leading to
involuntary passage of urine.
MODALITIES:- < morning, > N.S

PAST HISTORY
No history of any major
illness, operations or
accidents.
X-Ray exposure :- exposed
Vaccinations:- done

FAMILY HISTORY
MOTHER:- Hypertensive
FATHER :- expired (PUO?)
2 brothers and 1 sister :- all alive and
apparently well.

PERSONAL HISTORY
DEVELOPMENTAL LANDMARKS:- On time.
DIET:- Non-veg.
HABITS/ADDICTIONS:- N.S
OCCUPATION:- Housewife
EDUCATION:- Till 12th class.
ENVIRONMENT AT HOME:- Congenial.

GYNAE AND OBS.HISTORY

Menarche:- 15yrs of age.
Cycle:- irregular, 6-7 mnths gap, since 1 yr.
Duration :- 3-4 days.
Character:- red, no associated complaints.
obs. history :- G3P2L2A1
Son- 19 yrs., daughter- 14yrs.
Both FTNVDs.
Complaint of joint pains started after 1st
delivery.

PHYSICAL GENERALS
THERMAL REACTION :- ambithermal
APPETITE :- normal, 3meals/day
THIRST :- normal, takes a large quantity at a time.
DESIRES :- N.S
AVERSIONS :- sweets (1+)
URINE :- every 5-10 min. during daytime, N 3-4
STOOL :- D2-3N0-1, satisfactory
SLEEP :- 7-8 hrs., refreshing
DREAMS :- N.S
PERSPIRATION :- more on face, non-offensive, nonstaining.

MENTAL GENERALS
ANGER (1+)
IRRITABILITY(1+)
MEMORY- intact
FEARS:- N.S
LOQUACIOUS

INVESTIGATIONS DONE
ROUTINE HAEMOGRAM
Hb.:- 6.2gm%, TLC :- 9,800/cumm, DLC:- P 68L29E2M1
BSF :- 89mg/dl
URINE EXAMINATION:ROUTINE:- colour-pale yellow, reaction-acidic, sugar-nil
protein- trace
Microscopic- RBCs-nil, WBCs- 10-12/Hpf, epithelial cells4-6/Hpf
bacteria (++++)
STOOL EXAMINATION :- NAD
USG (whole abdomen) :- NAD

X-Ray chest :- lungs show prominent reticular

markings.
BOTH KNEE JOINTS :- advanced
osteoarthritis, bones are osteoporotic.
BOTH HANDS :- subluxation at intercarpal
joints, diminished joint space, osteoporosis.
BOTH ANKLE JOINTS:- osteoporosis with
diminished joint space.
IMPRESSION:- Rheumatoid arthritis with
superimposed osteoarthritis.

RUBRICS FOR REPERTORISATION

(KENTS REPERTORY)
1. Extremities, pain, joints (pg. 1047)
2. Extremities, pain, joints, cold weather (pg.1047)
3. Extremities, pain, joints, motion (pg. 1048)
4. Extremities, pain, joints, warmth, amel. (pg. 1048)
5. Extremities, stiffness, joints (pg. 1191)
6. Extremities, swelling, joints (pg. 1196)
7. Bladder, urging, constant (pg. 653)
8. Bladder, urination, frequent (pg. 657)
9. Bladder, urination, frequent, morning(pg.657)
10.Stomach, aversion, sweets (pg. 482)
11.Mind, irritability (pg.57)
12.Mind, loquacious (pg. 63)

REPERTORIAL RESULT
SULPHUR
CAUSTICUM
NUX-VOM
ARS.ALB
PHOS.
LYCOPODIUM
BELLADONA
CALC-CARB
RHUS TOX

22/9
19/9
19/9
17/9
16/9
18/8
17/8
17/8
17/7

PRESCRIPTION TILL DATE

Formica Rufa 30 / 5 doses.
Causticum 0/1/ 9 doses.
Apis 30 / 16 doses.
Guaicum 30 on 25-03-08.

PROVISIONAL
DIAGNOSIS
RHEUMATOID
ARTHRITIS

RHEUMATOID ARTHRITIS
Rheumatoid arthritis (RA) is traditionally considered
a chronic, inflammatory autoimmune disorder that
causes the immune system to attack the joints.
It is a disabling and painful inflammatory condition,
which can lead to substantial loss of mobility due to
pain and joint destruction.
RA is a systemic disease, often affecting extra-articular
tissues throughout the body including the skin,
blood vessels, heart, lungs, and muscles.

SIGNS AND SYMPTOMS

SYNOVITIS
Synovitis affecting synovial joints is the most prominent
feature in rheumatoid arthritis.
Inflammation in the joints manifests itself as a soft, "doughy"
swelling, pain, tenderness to palpation and movement,
local warmth, and functional impairment. Morning
stiffness is often a prominent feature and may last for
more than an hour. These signs help distinguish rheumatoid
and other inflammatory arthritides from non-inflammatory
diseases of the joints such as osteoarthritis (sometimes
referred to as the "wear-and-tear" of the joints). In RA, the
joints are usually affected in a fairly symmetrical fashion
although the initial presentation may be asymmetrical.

Rheumatoid arthritis is a systemic disorder mainly affecting

synovial joints. Chemical mediators (Cytokines) released
as a result of an abnormal immune reaction triggered by yet
undetermined agent/ agents, immune system releases
cytokines which gives rise to inflammation of joint synovium
(Synovitis). Constitutional symptoms such as fever,
malaise, loss of appetite and loss weight are also due to
cytokines released in to the blood stream due to an abnormal
immune reaction. Vasculitis affecting many other organ
systems often gives rise to systemic complications. Most
common and disabling clinical feature in Rheumatoid arthritis
is chronic, deforming, often symmetrical polyarthritis
(affecting multiple joints) due to joint Synovitis triggered by an
autoimmune reaction in genetically susceptible individuals .

DEFORMITY
As the pathology progresses the inflammatory activity leads
to erosion and destruction of the joint surface, which
impairs their range of movement and leads to deformity.
The fingers are typically deviated towards the little finger (
ulnar deviation) and can assume unnatural shapes.
Classical deformities in rheumatoid arthritis are the
Boutonniere deformity (Hyperflexion at the
proximal interphalangeal joint with hyperextension at the
distal interphalangeal joint ), swan neck deformity
(Hyperextension at the proximal interphalangeal joint ,
hyperflexion at the distal interphalangeal joint ). The thumb
may develop a "Z-Thumb" deformity with fixed flexion and
subluxation at the metacarpophalangeal joint , and
hyperextension at the IP joint.

Hand
affected by
RA

EXTRA-ARTICULAR
(ELSEWHERE)
Patients with RA usually exhibit signs of systemic
inflammation, that is, the inflammatory process in the
joint leaves its marks on other organs as well (and this
may also help distinguish it from osteoarthritis).
Examples are a general tiredness and lassitude,
sometimes low-grade fever, and some abnormalities on
blood tests such as an elevated erythrocyte
sedimentation rate (ESR), and anemia, which is often
seen as a consequence of the disease itself (
anaemia of chronic disease ) although it may also be
caused by gastrointestinal bleeding as a side effect of
drugs used in treatment, especially NSAIDs used for
analgesia.

Extra-articular manifestations (manifestations

outside the musculoskeletal system) occur in
about 15% of patients with rheumatoid
arthritis.
Examples are hepatosplenomegaly which may
occur with concurrent leukopenia and is then
referred to as Felty's syndrome), lymphocytic
infiltration affecting the salivary and lacrimal
glands (Sjgren's syndrome), pericarditis,
pleurisy, alveolitis, scleritis, and subcutaneous
nodules.

CUTANEOUS
MANIFESTATIONS
The rheumatoid nodule is the cutaneous (strictly speaking
subcutaneous) feature most characteristic of rheumatoid
arthritis. The mature lesion is defined by an area of
central necrosis surrounded by palisading macrophages
and fibroblasts and a cuff of cellular connective tissue and
chronic inflammatory cells. The typical rheumatoid nodule
may be a few millimetres to a few centimetres in
diameter and is usually found over bony prominences,
such as the olecranon, the calcaneal tuberosity, the
metacarpophalangeal joints, or other areas that sustain
repeated mechanical stress. Nodules are associated with
a positive RF titer and severe erosive arthritis. They can
rarely occur throughout the body in internal organs.

Several forms of vasculitis are also cutaneous

manifestations associated with rheumatoid arthritis.
A benign form occurs as microinfarcts around the
nailfolds. More severe forms include livedo reticularis
, which is a network (reticulum) of erythematous to
purplish discoloration of the skin due to the presence
of an obliterative cutaneous capillaropathy. (This
rash is also otherwise associated with the
antiphospholipid-antibody syndrome, a
hypercoagulable state linked to antiphospholipid
antibodies and characterized by recurrent vascular
thrombosis and second trimester miscarriages.

 Other, rather rare, cutaneous features include:

pyoderma gangrenosum, a necrotizing, ulcerative,
noninfectious neutrophilic dermatosis.
Sweet's syndrome, a neutrophilic dermatosis usually
associated with myeloproliferative disorders
viral infections
drug reactions
erythema nodosum
lobular panniculitis
atrophy of digital skin
palmar erythema
diffuse thinning (rice paper skin), and skin fragility.

OTHERS
Pulmonary
The lungs may become involved as a part of the primary disease
process or as a consequence of therapy. Fibrosis may occur
spontaneously or as a consequence of therapy (for example
methotrexate). Caplan's syndrome describes lung nodules in
patients with rheumatoid arthritis and exposure to coal dust.
Pleural effusions are also associated with rheumatoid arthritis.
Renal
Amyloidosis can occur.
Cardiovascular Possible complications that may arise include:
pericarditis, endocarditis, left ventricular failure, valvulitis and
fibrosis. The risk of cardiovascular, specifically
myocardial infarction (heart attack) or congestive heart failure
are greater in individuals with RA. Over 1/3 of deaths of people
with RA are directly attributable to cardiovascular death.

Ocular
Keratoconjunctivitis sicca (dry eyes), scleritis,
episcleritis and scleromalacia.
Gastrointestinal and Hematological
Felty syndrome, anemia
Neurological
Peripheral neuropathy and mononeuritis multiplex
may occur. The most common problem is carpal
tunnel syndrome due to compression of the
median nerve by swelling around the wrist.

Atlanto-axial subluxation can occur, owing to erosion of

the odontoid process and or/transverse ligaments in
the cervical spine's connection to the skull. Such an
erosion (>3mm) can give rise to vertebrae slipping
over one another and compressing the spinal cord. At
first the patient experiences clumsiness but without
due care this can progress to quadriplegia. Vasculitis in
rheumatoid arthritis is common. It is typically presents
as vasculitic nailfold infarcts. Osteoporosis classically
occurs in RA around inflamed joints. It is postulated to
be partially caused by inflammatory cytokines. The
incidence of lymphoma is increased in RA as it is in
most autoimmune conditions.

DIAGNOSIS
Diagnostic criteria
The American College of Rheumatology has defined (1987) the
following criteria for the classification of rheumatoid arthritis:
Morning stiffness of >1 hour most mornings for at least 6
weeks.
Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups,
present for at least 6 weeks
Arthritis of hand joints, present for at least 6 weeks
Symmetric arthritis, present for at least 6 weeks
Subcutaneous nodules in specific places
Rheumatoid factor at a level above the 95th percentile
Radiological changes suggestive of joint erosion
At least four criteria have to be met for classification as RA.

BLOOD TESTS
When RA is being clinically suspected,
immunological studies are required, such as
rheumatoid factor (RF, a specific antibody).
negative RF does not rule out RA; rather, the
arthritis is called seronegative.
During the first year of illness, rheumatoid factor is
frequently negative. 80% of patients eventually
convert to seropositive status. RF is also seen in
other illnesses, like Sjgren's syndrome, and in
approximately 10% of the healthy population,
therefore the test is not very specific.

 Because of this low specificity, a new serological

test has been developed in recent years, which
tests for the presence of so called
anti-citrullinated protein antibodies (ACPA).
Like RF, this test can detect approximately 80% of
all RA patients, but is rarely positive in non-RA
patients, giving it a specificity of around 98%.
In addition, ACP antibodies can be often detected
in early stages of the disease, or even before
disease onset. Currently, the most common test for
ACP antibodies is the anti-CCP (
cyclic citrullinated peptide) test.

Also, several other blood tests are usually done to

allow for other causes of arthritis, such as lupus
erythematosus. The erythrocyte sedimentation
rate (ESR), C-reactive protein,full blood count,
renal function, liver enzymes and other
immunological tests (e.g. antinuclear
antibody/ANA) are all performed at this stage.
Ferritin can reveal hemochromatosis, which can
mimic RA.

PROGNOSIS
The course of the disease varies greatly from patient to
patient. Some patients have mild short-term
symptoms, but in most the disease is progressive for
life. Around 20%-30% will have subcutaneous
nodules (known as rheumatoid nodules); this is
associated with a poor prognosis.
Disability
Daily living activities are impaired in most patients.
After 5 years of disease, approximately 33% of
patients will not be working
After 10 years, approximately half will have
substantial functional disability.

PROGNOSTIC FACTORS
Poor prognostic factors include
persistent synovitis, early erosive disease,
extra-articular findings (including subcutaneous
rheumatoid nodules),
positive serum RF findings,
positive serum anti-CCP autoantibodies,
carriership of HLA-DR4 "Shared Epitope" alleles,
family history of RA,
poor functional status,
socioeconomic factors,
elevated acute phase
response (erythrocyte sedimentation rate [ESR],
C-reactive protein [CRP]),
and increased clinical
severity.

What causes rheumatoid

arthritis?
The cause of rheumatoid arthritis is unknown. Even though
infectious agents such as viruses, bacteria, and fungi
have long been suspected.
The tendency to develop rheumatoid arthritis may be
genetically inherited.
It is suspected that certain infections or factors in the
environment might trigger the immune system to attack
the body's own tissues, resulting in inflammation in
various organs of the body such as the lungs or eyes.
Environmental factors also seem to play some role in
causing rheumatoid arthritis. Recently, scientists have
reported that smoking tobacco increases the risk of
developing rheumatoid arthritis.

PATHOPHYSIOLOGY
A joint (the place where two bones meet) is surrounded by
a capsule that protects and supports it. The joint
capsule is lined with a type of tissue called synovium,
which produces synovial fluid that lubricates and
nourishes joint tissues.
In rheumatoid arthritis, the synovium becomes inflamed,
causing warmth, redness, swelling, and pain.
As the disease progresses, the inflamed synovium invades
and damages the cartilage and bone of the joint.
Surrounding muscles, ligaments, and tendons become
weakened. Rheumatoid arthritis also can cause more
generalized bone loss that may lead to osteoporosis
(fragile bones that are prone to fracture).

GOALS OF TREATMENT
Relieve pain
Reduce inflammation
Slow down or stop joint damage
Improve a person's sense of well-being and
ability to function

CURRENT TREATMENT
APPROACHES
Lifestyle
Medications
Surgery
Routine monitoring and ongoing care

MANAGEMENT
Health behavior changes:
Rest and exercise: People with rheumatoid arthritis need a
good balance between rest and exercise, with more rest
when the disease is active and more exercise when it is not.
Rest helps to reduce active joint inflammation and pain and
to fight fatigue. The length of time for rest will vary from
person to person, but in general, shorter rest breaks every
now and then are more helpful than long times spent in bed.
Exercise is important for maintaining healthy and strong
muscles, preserving joint mobility, and maintaining flexibility.
Exercise can also help people sleep well, reduce pain,
maintain a positive attitude, and lose weight. Exercise
programs should take into account the person's physical
abilities, limitations, and changing needs.

Joint care:
Some people find using a splint for a short time around
a painful joint reduces pain and swelling by supporting
the joint and letting it rest. Splints are used mostly on
wrists and hands, but also on ankles and feet. A doctor
or a physical or occupational therapist can help a
person choose a splint and make sure it fits properly.
Other ways to reduce stress on joints include self-help
devices (for example, zipper pullers, long-handled
shoe horns); devices to help with getting on and off
chairs, toilet seats, and beds; and changes in the ways
that a person carries out daily activities.

Stress reduction:
People with rheumatoid arthritis face emotional challenges
as well as physical ones. The emotions they feel because of
the disease-fear, anger, and frustration-combined with any
pain and physical limitations can increase their stress level.
Stress also may affect the amount of pain a person feels.
There are a number of successful techniques for coping with
stress.
Regular rest periods can help, as can relaxation, distraction,
or visualization exercises. Exercise programs, participation
in support groups, and good communication with the health
care team are other ways to reduce stress.

SURGERY
Joint replacement: This is the most frequently performed surgery
for rheumatoid arthritis, and it is done primarily to relieve pain and
improve or preserve joint function. Artificial joints are not always
permanent and may eventually have to be replaced. This may be
an important consideration for young people.
Tendon reconstruction: Rheumatoid arthritis can damage and
even rupture tendons, the tissues that attach muscle to bone. This
surgery, which is used most frequently on the hands, reconstructs
the damaged tendon by attaching an intact tendon to it. This
procedure can help to restore hand function, especially if the
tendon is completely ruptured.
Synovectomy: In this surgery, the doctor actually removes the
inflamed synovial tissue. Synovectomy by itself is seldom
performed now because not all of the tissue can be removed, and it
eventually grows back. Synovectomy is done as part of
reconstructive surgery, especially tendon reconstruction.

DIFFERENTIAL
DIAGNOSIS
1.OSTEOARTHRITIS
2.SEPTIC ARTHRITIS
3.GOUT AND PSEUDOGOUT
4.SYSTEMIC LUPUS
ERYTHEMATOSUS
5.PSORIATIC ARTHRITIS

HOMOEOPATHIC
THERAPEUTICS
FORMICA RUFA
An arthritic medicine. Gout and articular
rheumatism; pains worse, motion; better,
pressure. Right side most affected.
Extremities.--Rheumatic pains; stiff and contracted
joints. Muscles feel strained and torn from their
attachment. Weakness of lower extremities.
Paraplegia. Pain in hips. Rheumatism comes on
with suddenness and restlessness. Sweat does
not relieve. Relief after midnight and from
rubbing.

STELLARIA MEDIA
Sharp, shifting, rheumatic pains in all parts very
pronounced. Rheumatism; darting pains in almost
every part; stiffness of joints; parts sore to touch;
worse, motion. Chronic rheumatism. Shifting
pains (Puls; Kali sulph). Psoriasis. Enlarged and
inflamed gouty finger joints.
Pain in shoulders and arms. Synovitis. Bruised
feeling. Rheumatic pains in calves of legs.
Modalities.--Worse, mornings, warmth, tobacco.
Better, evenings, cold air, motion.

BRYONIA ALBA
rheumatic pains and swellings; Knees stiff and painful.
Hot swelling of feet. Joints red, swollen, hot, with
stitches and tearing; worse on least movement. Every
spot is painful on pressure. Constant motion of left arm
and leg (Helleb).
RHUS TOXICODENDRON
Rhus affects fibrous tissue markedly-joints, tendons,
sheaths-aponeurosis, etc, producing pains and stiffness.
Rheumatism in the cold season. Hot, painful swelling of
joints. Pains tearing in tendons, ligaments, and fasci.
Rheumatic pains spread over a large surface at nape of
neck, loins, and extremities; better motion (Agaric).

KALMIA LATIFOLIA
A rheumatic remedy. Pains shift rapidly. Deltoid
rheumatism especially right. Pains from hips to
knees and feet. Pains affect a large part of a limb,
or several joints, and pass through quickly.
Weakness, numbness, pricking, and sense of
coldness in limbs. Pains along ulnar nerve, index
finger. Joints red, hot, swollen. Tingling and
numbness of left arm. Worse, leaning forward
(opposite, Kali carb); looking down; motion, open
air.

LITHIUM CARBONICUM
Chronic rheumatism connected with heart lesions
and asthenopia offer a field for this remedy.
Rheumatic nodes.
Paralytic stiffness all over. Itching about joints.
Rheumatic pains throughout shoulder-joint, arm,
and fingers and small joints generally. Pain in hollow
of foot, extending to knee. Swelling and tenderness
of finger and toe joints; better, hot water. Nodular
swellings in joints. Ankles pain when walking.
Worse, in morning, right side. Better, rising and
moving about.

COLCHICUM
shifting rheumatism; pains worse at night. Sharp
pain down left arm. Tearing in limbs during warm
weather, stinging during cold. Pins and needles in
hands and wrists, fingertips numb. Pain in front of
thigh. Right plantar reflex abolished. Limbs, lame,
weak, tingling. Pain worse in evening and warm
weather. Joints stiff and feverish.
ARNICA MONTANA
Rheumatism begins low down and works up
(Ledum).

LEDUM PALUSTRE
Rheumatism begins in lower limbs and
ascends (Kalmia opposite). Ankles
swollen. Gouty pains shoot all
through the foot and limb, and in
joints, but especially small joints.
Swollen, hot, pale.

GUAIACUM
Rheumatic pain in shoulders, arms and hands. Growing
pains (Phos ac). Pricking in nates. Sciatica and
lumbago. Gouty tearing, with contractions. Immovable
stiffness. Ankle pain extending up the leg, causing
lameness. Joints swollen, painful, and intolerant of
pressure; can bear no heat. Stinging pain in limbs.
Arthritic lancinations followed by contraction of limbs.
A feeling of heat in the affected limbs.
Modalities.--Worse, from motion, heat, cold wet
weather; pressure, touch, from 6 pm to 4 am. Better,
external pressure.