1601006070 SHORT CASE

 

Final Exam Short Case

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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