1601006045 LONG CASE

 A 50 YEAR OLD FEMALE


 A 50 year old female came to the OPD with  


CHIEF COMPLAINTS- 

  • Pain 
  • Stiffness in several joints since three months

HISTORY OF PRESENTING ILLNESS-

  • Patient was apparently asymptomatic 10 years ago then she developed a dull aching type of pain and stiffness in her metacarpophalangeal joints in her right hand associated with limitation of movements at the joint .

  • Then within 6 months of the onset of the disease, it has progressed to involve other joints of the right hand,left hand as well as wrist and elbow joint 

  • Then within 4 years of onset she started feeling pain in the joints of feet and ankle 

  • Since 3 months the pain became unbearable limiting her activities.

  • PAIN  was insidious in onset,slowly progressive,dull aching type of pain,non radiating,associated with swelling ,stiffness and limitation of movements in the involved joint.
     
  • STIFFNESS and PAIN was more in the first one hour of waking up and gradually improved with movements 

  • There are few exacerbations associated with fever 

  • No deformities 

  • No loss of weight 


PAST HISTORY-


  • She has no similar complaints 10 years ago 

  • No history of thyroid ,asthma,diabetes,TB,epilepsy 


DRUG HISTORY-

 

  • No known drug allergies 


MENSTRUAL HISTORY-


  • Menarche - 13 years 

  • She has regular cycles of 29 days duration 

  • Menopause - 47 years 


FAMILY HISTORY- 

  • No significant family history 


PERSONAL HISTORY-


  • Diet - mixed
  • Appetite - normal 
  • Bowel and bladder movements - regular 
  • Sleep - adequate


GENERAL EXAMINATION-

  • Patient is conscious,coherent,cooperative
  • Moderately built and nourished 
  • No pallor
  • No icterus
  • No cyanosis
  • No clubbing
  • No lymphadenopathy 
  • No Edema 


VITALS-


  • Temperature - afebrile 
  • Blood pressure - 115/70 mm Hg 
  • Respiratory rate - 15 cycles / min 
  • Pulse - 70 bpm


LOCAL EXAMINATION-


INSPECTION-

  • Skin-No subcutaneous nodules 

  • No pigmentation 

  • No scars 

  • No atrophic changes 

  • No purpura 

  • No ulcerations 

  • No gangrene 
  • Nail-Normal 

  • Soft tissues -swelling over the joints 

  • Deformities- No deformities in hands and feet 

    

PALPATION-

  • Skin - warm 

  • Sensations are present 

  • Soft tissues- no edema 

  • Joint capsule - mild swelling over the joint 

  • Tenderness over the joint -SQUEEZE TEST +ve 

  • Movements - decreased range of movements at PIP,MCP,wrist,elbow,ankle joints 

  • All active and passive movements at the involved joints are painful

  • No crepitus 

EUROPEAN LEAGUE AGAINST RHUEMATISM (EULAR)CRITERIA- total score of 7

-small joints affected 1-3,score of 2

-serology -high positive RF,score of 3

-acute phase reactants ESR,CRP ,score 1

-duration of symptoms->6 weeks ,score 1


SYSTEMIC EXAMINATION-


CVS-

  • Apex beat - 5th intercostal space medial to midclavicular line 

  • S1 S2 heard 

  • JVP normal 

  • Pedal edema - absent 


RESPIRATORY SYSTEM-


  • Breath sounds - normal 

  • No additional breath sounds 


CNS-

  • Sensations - preserved 

  • Joint position sense - intact 
  • Gait - normal 
  • Cranial nerves -intact 
  • Reflexes - preserved 

ABDOMEN - 

  • No abnormal findings found 


INVESTIGATIONS-


-Complete blood picture 

-ESR 

-CRP 

-Rheumatoid factor 

-Anti nuclear antibodies 

-Liver function test 

-Urine examination 

-Synovial fluid examination 

-Kidney function tests







PROVISIONAL DIAGNOSIS

RHEUMATOID ARTHRITIS 

TREATMENT

1.Prednisolone

2.Hydrocortisone sodium

3.Tramadol


                                              





 

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