1601006070 SHORT CASE

 

Final Exam 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 . 


INTRODUCTION

A 50 year old lady resident of Nalgonda who is a homemaker came to the OPD with the chief complaints of

- 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 pain and stiffness in her metacarpophalangeal joints of her right hand which was associated with limitation of movements at the joint.

- In the next 6 months, it has progressed to involve other joints of the right hand and the wrist and elbow joints of left hand also.

- In the next 4 years she started feeling pain in the joints of feet and ankle too.

- In the last 3 months the pain became unbearable limiting her activities.


- PAIN  was insidious in onset,slowly progressive,dull aching, non radiating, associated with swelling, stiffness and limitation of movements in the involved joint.

- STIFFNESS and PAIN is 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 , hypertension ,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

- Consent obtained

- Patient is conscious,coherent,cooperative

Moderately built and nourished 

-No pallor, icterus, cyanosis, clubbing, lymphadenopathy, 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 

Nails-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 


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

X ray


C-Reactive protein: positive


ESR: Elevated


Rheumatoid factor: strongly positive 
Anti CCP antibodies: negative







PROVISIONAL DIAGNOSIS

RHEUMATOID ARTHRITIS 

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