Medicine Case
Discussion
This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs
This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.
S.Kavya sree
1701006164
Case discussion
A 40 year old female patient came to the OPD with the complaints of
pain and stiffness in the small joints since 2 months
History of presenting illness
Patient was apparently asymptomatic 5 years back, then she developed dull aching type of pain and stiffness of metacarpophalangeal joints in her right hand and associated with limitation of movement at the joint.
Then within 6 months of onset, the disease progressed to wrist joint of right hand and left hand joints .
Then within 2 years of onset, she developed pain in the feet and ankle joint.
Since 1month, she complaints of severe pain and limiting her daily activities.
Pain is insidious onset and progressive, dull aching type of pain,Non radiating type of pain, associated with swelling, stiffness and limitation of movements in the involved joints.
Stiffness and pain was more during first one hour of waking up and gradually improves with work.
Past history
No history of diabetes,hypertension,asthma, epilepsy, tuberculosis
Personal history
Diet - mixed,appetite normal, bowel and bladder regular, sleep adequate, no allergies and addictions
GENERAL EXAMINATION-
Patient is conscious,coherent,cooperative
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No Edema
VITALS-
Temperature - afebrile
Blood pressure - 115/70 mm Hg
Respiratory rate - 15 cycles / min
Pulse - 70 bpm
LOCAL EXAMINATION
INSPECTION
Skin-No subcutaneous nodules
No pigmentation
No scars
No atrophic changes
No purpura
No ulcerations
No gangrene
Nail-Normal
Soft tissues -Swelling over the joints
Deformities- No deformities in hands and feet
PALPATION
Skin - warm
Sensations are present
Soft tissues- no edema
Joint capsule - mild swelling over the joint
Tenderness over the joint
Movements - decreased range of movements at PIP,MCP,wrist,elbow,ankle joints
All active and passive movements at the involved joints are painful
No crepitus
SYSTEMIC EXAMINATION-
CVS
S1 S2 heard
JVP normal
RESPIRATORY SYSTEM-
Breath sounds - normal
No additional breath sounds
CNS-
Sensations - preserved
Joint position sense - intact
Gait - normal
Cranial nerves -intact
Reflexes - preserved
ABDOMEN -
No abnormal findings found
INVESTIGATIONS-
-Complete blood picture
-ESR
-CRP
-Rheumatoid factor
-Anti nuclear antibodies
-Liver function test
-Urine examination
PROVISIONAL DIAGNOSIS:
RHEUMATOID ARTHRITIS
TREATMENT
1.Prednisolone
2.Hydrocortisone sodium
3. Tramadol
Comments
Post a Comment