27 year old female with joint pains

 

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Name - S.Kavya, 9th sem

Roll no - 121

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

27 year old female patient presented with the complaints of joint pains affecting her daily activities

 

March 2019

  After 6 hours of sleep in the night she experienced pain , swelling , mild rise of temparature with restriction of movement of left elbow joint : slight flexion of elbow joint which lasted for one and half year 

Visted orthopedician and was on Tab PCM and ointment /gel and Tab Pan for one month but no improvement .

(She is pointing pain towards lateral epicondyle, capitulum, radial head)

September 2020

 she went for physiotherapy for right elbow joint pain 

Then 3-4 days later she started experiencing pain in the right ankle joint

At tarsal bones and fibula tibia joints ?subtalar, ? Tibiotalar. 

Pain redness swelling over joint present.

Pain was progressing and radiating from lateral to medial side and then to plantar aspect of foot 

Not relieved on medication even after 15 days

Feb 2021 

 she started experiencing pain over right wrist joint ? Arthritis She had been to a neurologist it didnt subside 

Along with that she had tremors of right hand 

July 2021

arthritis of left wrist and ankle .

Pattern : left elbow - right ankle - right wrist - left wrist - left ankle

Among all right wrist she is experiencing more pain. 

Difficulty in walking since 2020 sept after she experienced right ankle joint pain.

No sensory symptoms 

Past history

Not a known case of DM, HTN, Asthma, Epilepsy, TB, CVD

Personal History

Diet - mixed

Appetite - normal

Bowel and bladder - regular

Sleep - adequate

No addictions , allergies

Family History - Insignificant

General examination

Patient - conscious, coherent , cooperative

Well oriented 

No signs of pallor, icterus,cyanosis, lymphadenopathy ,clubbing, edema

Temperature - afebrile

Pulse - 90bpm

Blood pressure - 100/60 mmHg

Respiratory rate - 16cycles

Systemic examination

CVS - S1, S2 heard

Respiratory system - NVBS, BAE+

Per abdomen -soft and non tender

CNS - NFND

Examination of joints

Wrist joint : flexion limited on both sides

Extension markedly limited ( Rt>left)

Ulnar deviation : limited

Radial deviation : limited

Pronation and supination: partially able to do 

Ankle joint: plantar flexion markedly limited on right side than left

Dorsiflexion able to do 

Eversion markedly limited on right side 

Inversion able to do with difficulty

The joint involved earlier has progressed to greater limitation of movements than the one involved later.

Pain is usually more in the morning and decreased as day progresses.

She also complaints of pain in the buttock region intermittently since 4 years

 

Dx - Chronic inflammatory polyarticular asymmetric

? Spondyloarthropathy

Treatment

Tab ultracet 1/2 QID

Tab pregaba 75 po OD

Tab Indocap 75mg pO BD

Physiotherapy