1601006072 LONG CASE

 

1601006072


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

 A 50 year old female came to the OPD with  


CHIEF COMPLAINTS- 

  • 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 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 painbecame unbearable limitingher 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 

  • There are few exacerbations associated with fever 

  • No deformities 

  • No loss of weight 


PAST HISTORY-


  • She has no similar complaints 10 years ago 

  • No history of thyroid ,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-

  • 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 -SQUEEZE TEST +ve 

  • 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-


-Complete blood picture 

-ESR 

-CRP 

-Rheumatoid factor 

-Anti nuclear antibodies 

-Liver function test 

-Urine examination 

-Synovial fluid examination 

-Kidney function tests







PROVISIONAL DIAGNOSIS

RHEUMATOID ARTHRITIS 

TREATMENT

1.Prednisolone

2.Hydrocortisone sodium

3.Tramadol


                                              





 



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