FINAL EXAM LONG CASE

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FINAL EXAM LONG CASE

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A 50 year old female patient a resident of Nalgonda, 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 dull aching type of pain and stiffness in her finger joints(MCP joints) 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(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.

  • 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. 

No history of thyroid, Asthma, hypertension, diabetes 

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 : 

  1. Diet: mixed 
  2. Appetite: normal 
  3. Bowel and bladder: regular 
  4. Sleep: adequate 
  5. No addictions 

General examination: 

patient is conscious coherent and cooperative 

Moderately built and nourished 

  • No edema
  • No icterus 
  • No cyanosis 
  • No lymphadenopathy 
  • No pallor 

VITALS:

  1. Temperature: a febrile 
  2. Blood pressure: 115/70
  3. Respiratory rate: 15 CYCLES/MIN
  4. 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

Sensations are preserved 

Soft tissues: no edema 

Joint capsule: mild swelling over the joint 

Tenderness over the joint (squeeze test)

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 sicca)

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. Liver function tests 

6. Renal function tests 

7. Urine examination 

8. Antibodies 

9. X-ray 


X ray Findings: 
1. Decreased joint space 
2.osteoporosis 
3. Mild erosions 



Rheumatoid factor: strongly positive 
Anti CCP antibodies: negative



C-Reactive protein: positive 


ESR: Elevated




PROVISIONAL DIAGNOSIS:

                                               ACTIVE      RHEUMATOID ARTHRITIS 









TREATMENT:
1. Methyl prednisolone 
2. Hydrocortisone 
3. Tramadol hydrochloride 








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