A 46-year-old Thai woman presents with a 6-month history of painful swelling and tightness in her hands, wrists, and elbows with morning stiffness for over 2 hours.

• She noticed her fingers turn white and numb when exposed to cold, followed by bluish-purple discoloration and then intense redness on rewarming.
• She has heartburn, early satiety, and intermittent dysphagia for solids.
• She denies oral ulcers, photosensitivity, or alopecia.

Physical examination:  BT 37.0 C, RR 22/min, BP 132/84 mmHg, PR 94/min

• Diffuse edema and skin thickening and tightening extending from fingers (sclerodactyly) to proximal to the metacarpophalangeal (MCP) joints and elbows
• Cold extremities with delayed capillary refill with cyanotic discoloration of distal phalanges with digital ulcers 
• Tenderness and synovitis of the MCP, PIP, and wrist joints bilaterally
• Bibasilar crackles at both lungs with questionable loud P2 
• No facial rash, no photosensitivity rash, no rheumatoid nodules 
• No proximal muscle weakness 

Questions: 

1. What is the provisional diagnosis? 

2. What are the proper next step investigations? 

3. What is your plan for initial treatment?

โดย น.อ.หญิง อินทิรา  อุไรเลิศ อายุรแพทย์โรคข้อและรูมาติสซั่ม กองอายุรกรรม รพ.ภูมิพลอดุลยเดช กรมแพทย์ทหารอากาศ

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