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



Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006168 SHORT CASE

Image
  MEDICINE SHORT CASE This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  CASE PRESENTATION: 34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of  Chest pain
Read more