1601006055 LONG CASE

 

LONG CASE


1601006055


A 50 year old female came to the OPD with chief complaints of pain and stiffness in several joints since 3 months

History of present illness:

She was apparently asymptomatic 8 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(Metacarpo phalengeal joints) of right hand.

After 4 months of onset, the pain and stiffness progressed to invovle other joints( wrist joint and elbow joint) of both hands and ankles

Pain was insidious in onset

slowly progressive

dull aching type

non radiating

associated with swelling and limitation of movements of the involved joints.

Since 3 months the pain increased causing limitation of activities of daily living

Stiffness and pain was more in the morning for 1 hour after waking up and gradually improved on movement.


No deformities were present

No history of loss of weight.

Past history:

She has no similar complaints in the past(8yrs ago)

Not a known case of Hypertension, Diabetes Mellitus, Epilepsy, Thyroid, Tuberculosis and Bronchial Asthma.

No history of drug allergies


MENSTRUAL HISTORY

Age of Menarche: 13 years 

Regular 29 day cycles 

Age of Menopause: 47 years 

Family history:

No similar complaints in family members

Personal history:

Diet: mixed 

Appetite: normal 

Bowel and bladder movements : regular and normal

Sleep: adequate 

No addictions 

General examination:

patient is conscious coherent and cooperative 

Moderately built and nourished 

No pallor 

No cyanosis

No clubbing 

No generalised lymphadenopathy 

No bilateral pedal edema 


VITALS 

Temperature: afebrile 

Pulse rate:-80bpm regular rhythm ,normal volume and character,peripheral pulses present

Blood pressure: 120/70mmHg in right arm sitting position

Respiratory rate: 15cycles /min


Local examination:

INSPECTION 

Skin is normal.There is no pigmentation , No redness ,No scars ,No atrophic changes 

Nails: normal 

 swelling over the metacarpophalengeal joints of both hands is seen 

 no deformities seen



PALPATION

Skin: warm

Sensations are preserved 

Soft tissues: no edema 

Joint capsule: mild swelling over the joint 

Tenderness over the joint is present

Movements: 

Decreased range of movements at PIP, MCP, wrist, elbow, ankle joints 

All active and passive movements at the involved joints and painful.



Extraarticular manifestations:

Eyes: no dryness of eyes(keratoconjuctivitis sicca)
Ear: no hearing loss
Muscle : no muscle atrophy
GIT: no xerostomia, no parotid gland enlargement, no dysphasia
No lymphadenopathy 

DIAGNOSIS OF RHEUMATOID ARTHRITIS:-


EUROPEAN LEAGUE AGAINST RHEUMATISM CRITERIA (EULAR)


Criterion.                                                      

Score

JOINTS AFFECTED


1 large

0

2-10 small joints

1

1-3 small joints                                          

2

4-10 small joints

3

>10 joints

5

SEROLOGY


Negative RF and ACPA.                                     

0

Low positive

2

High positive

3

DURATION OF SYMPTOMS


<6weeks

0

>6weeks

1

ACUTE PHASE REACTANTS


Normal CRP and ESR

0

Abnormal

1


**JOINTS AFFECTED:-

Involvement of metacarpophalengeal joints of both hands:- 2

**SEROLOGY:-
Rheumatoid factor positive (246IU/ml)- high positive:- 3

**DURATION OF SYMPTOMS:-8years
(>6weeks):- 1

**ACUTE PHASE REACTANTS:-
Abnormal ESR and CRP - 1

Total score:-
2 + 3 + 1 + 1= 7
Score greater than 6 suggestive of DEFINITE RHEUMATOID ARTHRITIS

Systemic examination:

CARDIOVASCULAR SYSTEM

Apex beat: 5th intercostal space medial to midclavicular line 

S1 and s2 heard 

No murmers  , no palpable thrills

JVP normal
Pedal edema: absent 

RESPIRATORY SYSTEM:

Breath sounds: normal vesicular breath sounds

No additional breath sounds 

CENTRAL NERVOUS SYSTEM:

cranial nerves intact 

Reflexes preserved

Sensations preserved 

Joint position sense: intact 

ABDOMEN

No abnormal findings found


INVESTIGATIONS:

1. Complete blood picture and ESR







2.CRP




3. Rheumatoid factor and antibodies



4.Liver function tests 



5.Urine examination 


6.X-ray 


 

7.ECG



PROVISIONAL DIAGNOSIS:

RHEUMATOID ARTHRITIS 




Treatment:

1.Prednisolone

2.Hydrocortisone sodium

3.Tramadol


                                              






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