Name: ________________ NRSG 201 Lab Case Study Dr.

Tower-Gilchrist

The below case study was pulled from WileyPlus. Please read the case carefully and answer the questions.

The Case of the Painful Hands

Mrs. Lewis is a 75 year old female that has been complaining of

pain in her hands.

Presenting symptoms
Pain and swelling in hands and feet
Morning stiffness
Bilateral (both right and left) involvement of joint areas
Increasing hand and foot deformities
Difficulty in performing daily tasks
Weakness
Weight loss
Family history of similar complaints

Physical exam:
Metacarpo-phalangeal and proximal interphalangeal joints are
swollen, warm to the touch and tender
Ulnar deviation of fingers at metacarpo-phalangeal joints
Large subcutaneous nodule near the olecranon process of right
elbow

Vital signs:
Blood pressure 130/85; Heart rate 90 beats/min; and Temperature 99.7degrees F

Lab results:
Blood
 White blood cells 13, 000/mm3
 Test for rheumatoid factor:
positive
 Erythrocyte sedimentation rate
(ESR) 35mm/hr

Synovial fluid analysis:

 Appears cloudy, white blood
cells 20,000/mm3
 Test for rheumatoid factor:
positive
 Absence of bacteria
 Absence of crystals such as
urate associated with gout

Hand X-ray:
 Ulnar deviation at metacarpophalangeal joints, metacarpal dislocations, flexion of interphalangeal joints
We can begin with looking at the defects that were observed including chemical, cellular, and tissue defects.
Chemical Defects
In affected joints, cells of the immune secrete certain enzymes that
destroy the articular cartilage and underlying bone.
- Collagenase destroys collagen
- Protease destroy the components of the ground substance
Bone destruction and deformity reduces the joint’s range of motion.

Cellular Defects
In disease joints, articular cartilage is damaged by actions of cells:
T lymphocytes Plasma cells
Macrophages Neutrophils
Synociocytes Chondroblasts

Plasma cells participate in immune response when activated by T

lymphocytes. They secrete large quantities of antibodies; damage
collagen in cartilage matrix when immune system is in disorder; and
produce antibodies called rheumatoid factors that attack other
antibodies.

Macrophages ingest debris and dead cells in sites of infection or

inflammation. Stimulate fibroblast proliferation in the joint, leading to
fusion of the articulating bones and deformity; stimulate synoviocytes to
release collagenase and protease, causing cartilage and bone
destruction; inhibit proteoglycan formation, hampering matrix repair.

T lymphocytes release enzymes that normally attack bacteria and

diseased cells. Damage healthy cartilage when immune system is in disorder, and cause inflammation that attracts and
activates other white blood cells.

Neutrophils migrate to the inflamed joint early in the disease process. Phagocytize RFs already formed in the joint.
Release collagenases and proteases that destroy joint cartilage and bone.

Let’s take a look at the structures that are found within a joint.

Articular cartilage- the smooth, protective weight-bearing surface

of a synovial joint allows articulating bones to move and slide
against each other during movement

Synovial fluid- found within the joint cavity, this fluid lubricates
the joint and proves nutrients to cells of the articular cartilage

Hyaline cartilage –this primary tissue of the articular cartilage is

compose of chondrocytes in lacunae and a matrix

Matrix
-Collagen fibers form a structural frameworks that provides
strength and flexibility
-Gel-like ground substance contains proteoglycans and hyaluronic acid and provides resistance to compression
Tissue Defects
Mrs. Lewis suffers from a condition that affects distal joints.

Changes to synovial membrane

 The synovial membrane is thickened due to proliferation of
synovial cells.
 Finger-like projections push into the joint cavity.
 Connective tissue houses lymphoid nodules which contain tissue
damaging immune cells.

The pathological hallmark of this condition which is a pannus, thickened layer of synovial membrane, that erodes
cartilage.
 Normal joint (no pannus)
 Pannus forms and begins to invade cartilage
 Pannus continues to grows and reaches underlying bone
 Pannus spans the entire join space, fusing and deforming bones

Rheumatoid nodules are common in severe cases and often appear as bony prominences under the skin in the hand,
elbow, forearm, and knee. They consist of fibrotic scar tissue surrounded by lymphocytes and plasma cells.

The inflammation and tissue changes symptomatic of this disease can be observed in many different organ systems
o Skin: Subcutaneous rheumatoid nodules

o Eyes: Inflammation of sclera and dryness

o Joints: Inflammation, Stiffness, Deformity, reduced mobility, even Bursitis

o Tendon: Inflammation, Rupture, Pain

o Heart: Inflammation of pericardium

o Arteries: Vascular inflammation, reduced blood flow

o Lungs: Inflammation of pleura membranes, intrapulmonary rheumatic nodules

o Live: Autoimmune hepatitis

Questions:

1. Which of the following conditions BEST describes Mrs. Lewis’ clinical signs and symptoms?
a. Gout
b. Tennis elbow
c. Osteoporosis
d. Cerebral palsy
e. Rheumatoid arthritis

2. Which of the following BEST explains Mrs. Lewis’ elevated white blood cell count
a. Viral osteomyelitis (infection of bone)
b. Bacterial joint infection
c. Autoimmune destruction of joints
d. Bacterial pneumonia
e. Normal

3. Which of the following explain the pathological changes illustrated here

in this disease?
a. Atrophy
b. Infarction
c. Tumor
d. Inflammation
e. Normal

4. Which of these BEST explains Mrs. Lewis’ hand X-ray?

a. Infarction of bone tissue in 3rd metacarpal
b. Fusion and deformity at metacarpophalangeal and
interphalangeal joints
c. No evidence of abnormality so it is normal
d. Tumor
e. Fracture of the proximal phalanx, digit 2

5. What is the role of this cell type in the synovial membrane of Mrs.
Lewis’ Joints?
a. Secretes collagenase and proteases
b. Protects lymphoid nodules
c. Secretes antibodies
d. Contributes to matrix repair
e. Ingests debris and dead cells

6. Mrs. Lewis’ condition is initiated by a disorder in what system?

a. Nervous
b. Muscular
c. Skeletal
d. Cardiovascular
e. Immune
7. What is the role of this cell in the pathological change shown in figure to
right?
a. Secretes destructive antibodies
b. Secretes synovial fluid
c. Secretes rheumatoid factors
d. Stimulates fibroblast proliferation causing scar tissue formation
e. Produces a new bone at sides of inflammation

8. A joint crippling pannus develops directly from what?

a. Chronic fractures
b. Destruction of lymphoid nodules
c. Thickening of the synovial membrane
d. Deficiency of calcium
e. Formation of rheumatoid nodules