Welcome to the Hyperexcision podcast. This podcast is a time-efficient alternative to the written content on the website. It supplements the exam preparation material available on the hyperexcision.com website for medical students. You can follow along with the written material on the website while listening to this podcast. If you have any comments or suggestions, email [email protected].

Every case has a script. Clinical approach is a collection of hypothetical case discussions with questions that test the key concepts for a particular disease presentation.

A 42-year-old woman presents to the outpatient clinic with a 6-month history of joint pain and stiffness.

The pain initially started in the small joints of her hands and has progressively worsened. She describes morning stiffness lasting more than an hour, which improves as the day progresses. She reports swelling, warmth, and decreased grip strength. She also reports experiencing general fatigue, a low-grade fever, and weight loss over the past few months.

Upon examination, both hands exhibit symmetrical swelling and tenderness in the MCP and PIP joints, accompanied by mild ulnar deviation. The wrists are also tender and slightly limited in movement. There are no nodules seen over the extensor surfaces. Cardiovascular, respiratory, and neurological exams are unremarkable.

Laboratory results are as follows: haemoglobin is 10.5 — low. WBC is normal. Platelets are elevated at 420. ESR is markedly elevated at 72. CRP is elevated at 25. Rheumatoid factor is positive at 120 IU per millilitre. Anti-CCP antibodies are positive at high titre. ANA is negative. Serum creatinine is normal. Liver function tests are normal.

The X-ray of the hand shows generalised osteopaenia, severe erosion and destructive changes in the distal radius and ulna bilaterally as well as the carpal bones. Extensive joint space narrowing is seen at the intercarpal, carpometacarpal, and wrist joints. Erosive changes are seen along the head and base of the proximal phalanges.