1601006125 LONG CASE

This is an online E log book to discuss our patient’s de-identified data shared after taking her guardian’s signed informed consent.

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 presenting illness

Patient was apparently asymptomatic 5years ago then she developed bilateral small joint pains ,bilateral knee joint pains and swelling at left elbow but she never visited any hospital.

 

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

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  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
  Reflexes preserved    

  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. Osteoarthritis 

  2. Rheumatoid arthritis

  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 
•             RHEUMATOID ARTHRITIS
• TREATMENT
  1. METHYL PREDNISOLONE
  2. HYDROCORTISONE
  3. TRAMADOL HYDROCHLORIDE
  
•