1601006184 LONG CASE

 1601006184

LONG CASE:

A 50 year old female hailing from cherkupalli, housewife by occupation came to the OPD with
 chief complaints of pain and stiffness in several joints since 3 months. 

HISTORY OF PRESENTING ILLNESS:
She was apparently asymptomatic 9 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(metacarpophalyngeal joints) of right hand.

 After 5 months of onset, the pain and stiffness progressed to invovle other joints( wrist joint and elbow joint) of both hands.

Within 5 years of onset she started feeling pain in the joints of the feet and ankle. 

Pain was insidious in onset, slowly progressive, dull aching type, non radiating type,associated with swelling and limitation of movements of the involved joints.
Pain and stiffness were aggravated by rest and relieved on activity.

Since 3 months the pain was unbearable & was limiting her activities.

Stiffness and pain was more in the morning for 1 hour after waking up and gradually improved on movement.

Sometimes pain was associated with intermittent fever.

No deformities 
No loss of weight.

PAST HISTORY:
No history of any similar complaints 9 years ago.
Not a known case of diabetes, hypertension,asthma and thyroid.

DRUG HISTORY:
No known drug allergies

MENSTRUAL HISTORY:
Menarache : 15 years
Cycles :regular 29 days cycles
Menopause attained by 48 yrs

FAMILY HISTORY:
No similar history

PERSONAL HISTORY:
diet: mixed
Appetite :normal
Bowel & bladder :regular
Sleep : adequate
Addictions: no addictions
EXAMINATION:
GENERAL EXAMINATION:
   Patient is conscious, coherent, cooperative and well oriented to time and place.
She is moderately built and moderately nourished. 
No pallor , icterus,clubbing, koilonychia,lyphmadenopathy,edema.

Vitals
Temperature : Afebrile
Blood pressure: 120/80mmHg
Respiratory rate: 16cpm
Pulse rate: 82bpm

LOCAL EXAMINATION:

Inspection: 
Skin 
No pigmentation, scars , atrophic changes

and nails are normal.

Soft tissues
Mild swelling over the joints is seen.

Deformities
No deformities 

Palpation:
Skin 
 Warm

Sensations are preserved.

Soft tissue 
No edema

Joint capsule
Mild swelling over the joint is seen.
Tenderness over the involved joint is seen.(squeeze test)

Movements:
Decreased range of movements at PIP, MCP, wrist, elbow, ankle joints 

All active and passive movements at the involved joints are painful.

EUROPEAN LEAGUE AGAINST RHUEMATISM (EULAR)CRITERIA- Total score of 10
-joints affected, score of 5
-serology -high positive RF,score of 3
-acute phase reactants ESR,CRP ,score 1
-duration of symptoms->6 weeks ,score 1

Extraarticular manifestations:
Eyes: no ocular manifestations
Ear: no hearing loss
Muscle : no muscle atrophy
GIT: no xerostomia, no parotid gland enlargement, no dysphasia
No lymphadenopathy 

SYSTEMIC EXAMINATION

Cardiovascular examination

Apex beat: 5th intercostal space medial to midclavicular line 
S1 and s2 heard 
No murmers , no palpable thrills
JVP normal
Pedal edema: absent 

RESPIRATORY SYSTEM:

Breath sounds: normal 
No additional breath sounds 

CENTRAL NERVOUS SYSTEM:

cranial nerves intact 
Reflexes preserved
Sensations preserved 
Joint position sense: intact 

ABDOMEN:

No abnormal findings found

INVESTIGATIONS:

1. Complete blood picture 

2. ESR 

3. CRP

4. Rheumatoid factor 

5. Liver function tests 

6. Renal function tests 
7. Urine examination 

8. Antibodies 
9. X-ray 








PROVISIONAL DIAGNOSIS:
RHEUMATOID ARTHRITIS 


Treatment:
1.Prednisolone

2.Hydrocortisone sodium

3.Tramadol


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