LONG CASE

1601006013

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50 YEAR OLD FEMALE 

A 50 year old female came to the OPD with the chief complaints of pain and stiffness in several joints since 2 months

HISTORY OF PRESENT ILLNESS :

She was apparently asymptomatic 10 years ago, then she developed a dull aching type of pain and stiffness in her joints of the fingers (MCP joints) of right hand with limitation of movements at the joints. 

Then within 5 months of onset of the disease, it progressed to involve other joints of the right hand and left hand as well ( wrist joint and elbow joint ) 

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

Since 2 months the pain became unbearable  limiting  her activities. 

The pain was insidious in onset, slowly progressive dull aching type of pain, non radiating,aggravated by rest and relieved on activity and 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 intermittent fever.

No deformities 

No loss of weight.

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 :

Diet: mixed 

Appetite: normal 

Bowel and bladder: regular 

Sleep: adequate 

GENERAL EXAMINATION :

patient is conscious coherent and cooperative 

Moderately built and nourished 

No edema

No icterus 

No cyanosis 

No lymphadenopathy 

No pallor 

VITALS:

Temperature: afebrile 

Blood pressure: 115/70mmHg

Respiratory rate: 15cpm

Pulse rate: 72bpm

LOCAL EXAMINATION :

INSPECTION :

Skin : 

No pigmentation 

No scars 

No atrophic changes 

Nails: normal 

Soft tissues: mild 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 are painful .

Extra articular manifestations :

Eyes: no dryness of

eyes (keratoconjuctivitis sicca)

Ear: no hearing loss

Muscle : no muscle atrophy

GIT: no xerostomia, no parotid gland enlargement, no dysphagia 

No lymphadenopathy 

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM

Apex beat:  5th intercostal space located near the midclavicular line 

S1 and S2 heard 

JVP NORMAL 

Pedal edema : absent 

RESPIRATORY SYSTEM

Breath sounds: normal 

No additional breath sounds 

CENTRAL NERVOUS SYSTEM

Gait: normal 

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. Antibodies

6. Renal function tests 

7. Urine examination 

8.  Liver function tests

9. X-ray

PROVISIONAL DIAGNOSIS:

                                                

RHEUMATOID ARTHRITIS 

TREATMENT :

Hydrocortisone

Tremadol

Methyl prednisolone