Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with persistent left ankle pain, stiffness, and localized swelling, exacerbated by morning activity and prolonged weight-bearing. Symptoms are chronic in nature, unresponsive to NSAIDs. No history of trauma. Serological testing confirms negative Rheumatoid Factor (RF). Patient denies systemic constitutional symptoms, fever, or involvement of other joints.
Clinical Examination Findings
Physical examination of the left ankle reveals periarticular swelling, tenderness along the tibiotalar joint line, and restricted range of motion (ROM) in dorsiflexion and plantarflexion. No overlying erythema or warmth noted. Gait analysis shows antalgic pattern favoring the right side. Distal neurovascular status is intact. No palpable rheumatoid nodules.
Treatment Protocol
Initiate Disease-Modifying Antirheumatic Drug (DMARD) therapy (e.g., Methotrexate) as per protocol. Prescribe short-term low-dose corticosteroids for acute flare management. Recommend physical therapy for ankle stabilization and range-of-motion exercises. Follow-up in 4-6 weeks for laboratory monitoring (CBC, LFTs, Creatinine) and clinical reassessment.