1601006067 - Final Year Practical Long Case

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Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient - centred online learning portfolio and your valuable inputs in the comments.


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 3 months

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

- Then 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 *


Criterion.                                                      

Score

JOINTS AFFECTED


1 large joint

0        

2-10 large joints

1

1-3 small joints                                          

2

4-10 small joints

3

>10 joints

5

SEROLOGY


Negative RF and ACPA.                                     

0

Low positive

2

High positive

3

DURATION OF SYMPTOMS


<6weeks

0

>6weeks

1

ACUTE PHASE REACTANTS


Normal CRP and ESR

0

Abnormal

1


Here , 

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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