1601006064 SHORT CASE

 

Short case final exam

1601006064

This is my short case where a 

 50 year old female came to the OPD with  

CHIEF COMPLAINTS-

Pain 

Stiffness in several joints since one year 

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 10 years ago thent 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 

No deformities 

No loss of weight 

PAST HISTORY-

She has no similar complaints 10 years ago 

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

MEDICAL HISTORY- 

She has no similar complaints 8 years ago. 

No history of thyroid, Asthma, hypertension, diabetes 

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

No Addictions 

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 

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 

SYSTEMIC EXAMINATION-

CVS

Apex beat - 5th intercostal space lateral 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 








Xray


PROVISIONAL DIAGNOSIS:

     RHEUMATOID ARTHRITIS

TREATMENT

1.Prednisolone

2.Hydrocortisone sodium

3. Tramadol



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