1601006106 LONG CASE
FINAL EXAMINATION LONG CASE:
A 50 year old lady ,resident of Nalgonda, who is a home maker came to the OPD with chief complaints of pain and stiffness in several joints since 1 year.
History of present illness:
She was apparently asymptomatic 10 years ago, then she developed a dulling aching type of pain and stiffness in her finger joints(Metacarpo-phalangeal joints-MCP) of right hand with limitations of movements at the joints.
Then within 6 months of onset,the disease progressed to involve other joints of the right hand and left hand as well( both wrist joint and elbow joint)
Within 4 years of onset ,she started feeling pain in the joints of the feet and ankle joint.
Since 3 months the pain became unbearable limiting her activities
The pain was insidious in onset, slowly progressive, dull aching type of pain, non radiating, associated with swelling, stiffness and limitations of movements in the involved joints.
Stiffness and pain was more in the first 1 hour of waking up and gradually improved on movement.
There are few exacerbations associated with fever and sometimes with nodules over distal ulna.
- No deformities
- No loss of weight.
- No involvement of distal interphalangeal joint
- No butterfly rash
- No abnormal jerky movements (chorea)
Past history:
She has no similar complaints 10 years ago.
Hypertensive since 2years
Diabetic since 2years
No history of thyroid, Asthma,
Drug history:
No known drug allergies
Menstrual history:
- Menarch: 13 years
- Regular 29 day cycles
- Menopause: 47 years
Family history:
No similar complaints
Personal history :
Diet: mixed
Appetite: normal
Bowel and bladder: regular
Sleep: adequate
No addictions
GENERAL EXAMINATION:
Patient is conscious,coherent and cooperative
Moderately built and Moderately nourished
- No pallor
- No icterus
- No cyanosis ,no clubbing ,no koilonychia
- No lymphadenopathy
- No odema
VITALS:
•Temperature: afebrile
•Blood pressure: 115/70
•Respiratory rate: 15 cycles/mins
•Pulse rate: 76bpm
LOCAL EXAMINATION:
INSPECTION:
☆Skin : No pigmentation
No scars
No atrophic changes
☆Nails: normal
☆Soft tissues: swelling over the joints
☆Deformities : no deformities
PALPATION:
☆Skin: warm
☆Tenderness over the joint (squeeze test)
https://drive.google.com/file/d/1JtFtvpM66OVZpkylb8YngfJZCuzfgmrY/view?usp=drivesdk
☆Sensations are preserved
☆Soft tissues: no edema
☆Joint capsule: mild swelling over the joint
☆Movements:
•Decreased range of movements at PIP, MCP, wrist, elbow, ankle joints
•All active and passive movements at the involved joints and painful
EXTRA ARTICULAR MANIFESTATIONS:
Eye: no ocular manifestations (episcleritis,scleritis, keratoconjuctivitis)
Ear: no hearing loss
Muscle: no muscle atrophy
GIT: no xerostomia, no parotid gland enlargement ,no dysphasia.
No lymphadenopathy
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
☆Apex beat: 5th intercostal space lateral to midclavicular line
☆S1 and s2 heard
☆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
DIFFERENTIAL DIAGNOSIS
1. Rheumatoid arthritis
2.Osteoarthritis
INVESTIGATIONS:
1. Complete blood picture
2. ESR
3. CRP
4. Rheumatoid factor
5. Antibodies
6.Liver function tests
7. Renal function tests
8. Urine examination
9. X-ray
☆Synovial fluid analysis, synovial biopsy,arthroscopy rarely
