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A 50 year old female home maker resident of Nalgonda , came to OPD with chief complaints of
1. Pain
2. Stiffness in several joints since 1 year
History of presenting illness :
- Patient was apparently asymptomatic 10 years ago , then she developed a dull aching type of pain & stiffness in her metacarpophalangeal joints in her right hand which is associated with limitation of movements at the joint
- Within 6 months of onset , it progressed to involve other joints of the right & left hand as well as wrist & elbow joint
- Then within 4 years of onset , she started feeling pain in the joints of feet & ankle
- Since 3 months the pain became unbearable which limited her activities
- Pain was insidious in onset , slowly progressive , dull aching type , non radiating , associated with swelling & stiffness of the involved joint
- Stifness & Pain were more in the morning & gradually improved with movements
- No deformities
- No loss of weight
Past History :
- No similar complaints 10 years ago
- No history of Diabetes , Hypertension , TB , Asthma , Epilepsy , Thyroid
Drug History :
- No known drug allergies
Menstrual History :
- Age of Menarche at 13 years
- Regular cycles , 4/28 , No Pain , No clots
- Age of Menopause at 47 years
Family History :
- No significant family history
Personal History :
- Mixed Diet
- Normal Appetite
- Regular Bowel & Bladder movements
- Adequate Sleep
- No Addictions
General Examination :
- Patient consent was obtained
- Patient was Conscious , Coherent , Cooperative , Moderate Built & Nourished
- No Pallor , Icterus , Cyanosis , Clubbing , Lymphadenopathy , Edema
VITALS -
Temperature : Afebrile
Blood Pressure : 120 / 70 mmHg in right arm sitting position
Pulse : 80 beats / min , regular rhythm , normal volume & character
Respiratory Rate : 15 cycles / min
Local Examination :
INSPECTION :
- Swelling over the metacarpophalengeal joints in both hands
- No Subcutaneous nodules
- No pigmentation
- No scars
- No atrophic changes
- No purpura
- No ulcerations
- No gangrene
- No nail changes
- No deformities in hands & feet
PALPATION :
- Skin is warm
- Sensations are present
- Mild Swelling over the joint capsule
- Tenderness over the joint is present
- Decreased range Movements at PIP , MCP , Wrist , Elbow & Ankle joints
- All active & passive movements at the involved joints are painful
- No soft tissue edema
- No crepitus
Extra Articular Manifestations :
- No Ocular manifestations ( episcleritis , scleritis , keratoconjunctivitis sicca )
- No hearing loss
- No muscle atrophy
- No xerostomia , parotid gland enlargement , dysphagia
- No lymphadenopathy
Systemic Examination:
CVS :
- Apex beat at 5th intercostal space medial to midclavicular line
- S1 & S2 heard
- No Murmurs
- Normal JVP
RS :
- Normal Vesicular Breath Sounds are heard
- No added sounds
CNS :
- Sensations are preserved
- Joint position sense is intact
- Gait is normal
- Cranial nerves are intact
- Reflexes are preserved
ABDOMEN :
- No abnormal findings found
Investigations :
1. Complete blood picture
2. ESR : Elevated
3. CRP : Elevated
4. Rheumatoid factor :- Positive
5. Anti Cyclic Citrullinated Peptides ( CCP ) :- Negative
6. Liver Function tests
7. Urine examination
8. X - ray
Provisional Diagnosis :
Rheumatoid Arthritis
DIAGNOSIS OF RHEUMATOID ARTHRITIS:-
EUROPEAN LEAGUE AGAINST RHEUMATISM CRITERIA (EULAR)
* Score Greater than 6 is suggestive of Definite Rheumatoid Arthritis *
Joints affected :
1 large joint | 0 |
2-10 large joints | 1 |
1-3 small joints | 2 |
4-10 small joints | 3 |
>10 joints Serology : | 5 |
Negative RF and ACPA. | 0 |
Low positive | 2 |
High positive | 3 |
Duration of symptoms:
Acute phase reactants :
Normal CRP and ESR | 0 |
Abnormal | 1 |
Here , in this case :
A. Joints affected :
Involvement of MCP joints of both hands - Score of 2
B. Serology :
Rheumatoid Factor is Highly Positive - Score of 3
C. Acute Phase Reactants :
Abnormal ESR & CRP - Score of 1
D. Duration of Symptoms :
More than 6 weeks - Score of 1
TOTAL SCORE - 2 + 3 + 1 + 1 = 7 ( which is more than 6 )
Treatment :
1. Methyl prednisolone
2. Hydrocortisone
3. Tramadol hydrochloride
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