A 50 YEAR OLD FEMALE

A 50 YEAR OLD FEMALE

 A 50 year old female came to the OPD with  

CHIEF COMPLAINTS- 

• Pain 
• Stiffness in several joints since three months

HISTORY OF PRESENTING ILLNESS-

• Patient was apparently asymptomatic 10 years ago then she developed a dull aching type of pain and stiffness in her metacarpophalangeal joints in her right hand associated with limitation of movements at the joint .

• Then within 6 months of the onset of the disease, it has progressed to involve other joints of the right hand,left hand as well as wrist and elbow joint 

• Then within 4 years of onset she started feeling pain in the joints of feet and ankle 

• Since 3 months the pain became unbearable limiting her activities.

• PAIN  was insidious in onset,slowly progressive,dull aching type of pain,non radiating,associated with swelling ,stiffness and limitation of movements in the involved joint.

     

• STIFFNESS and PAIN was more in the first one hour of waking up and gradually improved with movements 

• There are few exacerbations associated with fever 

• No deformities 

• No loss of weight 

PAST HISTORY-

• She has no similar complaints 10 years ago 

• No history of thyroid ,asthma,diabetes,TB,epilepsy 

DRUG HISTORY-

 

• No known drug allergies 

MENSTRUAL HISTORY-

• Menarche - 13 years 

• She has regular cycles of 29 days duration 

• Menopause - 47 years 

FAMILY HISTORY- 

• No significant family history 

PERSONAL HISTORY-

• Diet - mixed
• Appetite - normal 
• Bowel and bladder movements - regular 
• Sleep - adequate

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 -SQUEEZE TEST +ve 

• 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 

EUROPEAN LEAGUE AGAINST RHUEMATISM (EULAR)CRITERIA- total score of 7

-small joints affected 1-3,score of 2

-serology -high positive RF,score of 3

-acute phase reactants ESR,CRP ,score 1

-duration of symptoms->6 weeks ,score 1

SYSTEMIC EXAMINATION-

CVS-

• Apex beat - 5th intercostal space medial to midclavicular line 

• S1 S2 heard 

• JVP normal 

• Pedal edema - absent 

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 

-Synovial fluid examination 

-Kidney function tests

PROVISIONAL DIAGNOSIS

RHEUMATOID ARTHRITIS 

TREATMENT

1.Prednisolone

2.Hydrocortisone sodium

3.Tramadol