45 year old female with Rheumatoid Arthritis
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Chief complaints:
Pain in wrists and ankles since 4 years
Neck pain since 4 years
Headache since 2 years
History of presenting illness :
Patient was apparently asymptomatic 4 years ago then she developed pain firstly in left ankle followed by left wrist ,neck , right wrist joints,PIP , metacarpophalengeal joints are also involved in right hand,insidious in onset gradually progressive aggrevated by work and relived on medication.
Pain is confined to joint .
H/O pain in neck which radiated to shoulders and relieved on medication.
No h/o myalgia
No h/ o trauma
No h/o swelling,deformity
History of morning stiffness and lasts for 2 hours .
Generalised weakness is present
Headache since 2 years not associated with nausea and vomitings
History of low grade fever intermittent in nature,not associated with chills and rigors
No h/o pain abdomen,loose stools,burning micturition,decreased urinary output
No h/o weight loss,loss of appetite , sweating.
No h/o conjuctivitis ,skin rash,ulcers
No h/o chest pain,palpitations,sweating .
Past history :
History of hysterectomy 20 years back
Not a known case of DM,HTN,Asthma,epilepsy,thyroid,CAD,TB
Personal History:
Mixed diet
Adequate sleep
Regular bowel and bladder movements
No smoking and no allergies
She use drink toddy since 12 years and she stopped since 4 years .
Family history:
Not relevant
General Examination:
Patient is conscious, coherent and co -operative
Pallor -absent
Icterus- absent
Clubbing - absent
Cyanosis - absent
lymphadenopathy - absent
Edema - absent
Temperature - 98.3 ° F
BP- 120/80 mm hg
PR - 73bpm
RR - 15cpm
Local examination:
Inspection
No redness, no swelling,no deformity
Palpation
No local rise of temperature
Tenderness over joints on palpation
Movements:
Mild restriction of movement in left ankle and left wrist, MCPs
Pain is associated with movement
Gait is normal.
Respiratory System
Inspection:
Trachea appears to be normal - Central
shape of chest - elliptical
Movements of chest appear to be bilaterally equal
No scars , sinuses present.
No drooping of shoulder
No engorged veins , swellings seen
No hallowing seen
No crowding of ribs
Palpation:
All inspectory findings are confirmed
No rise of temperature
No tenderness
Trachea is in midline
B/L chest movements are equal
No swelling and palpable masses are felt
vocal fremitus are normal
Apex beat is felt
PERCUSSION. RT. LT
SUPRA CLAVICULAR resonant. resonant
INFRA CLAVICULAR. resonant. resonant
MAMMARY. resonant. resonant
INFRA MAMMARY. resonant. resonant
AXILLARY. resonant resonant
INFRA AXILLARY. resonant resonant
SUPRA SCAPULAR. resonant resonant
INFRA SCAPULAR. resonant resonant
INTER SCAPULAR. resonant resonant
Auscultation :
Normal vesicular breath sounds heard.
Per abdomen:
Inspection -
Shape of abdomen : scaphoid
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins.
On palpation -
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion -
Resonance note heard
On auscultation -
Bowel sounds heard
Cardiovascular system:
Inspection-
No raised JVP
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse at 5th intercostal space
Palpation-
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard .
Central nervous system:
Conscious
Normal speech.
No neurological deficit found.
Provisional Diagnosis:
Rheumatoid Arthritis .
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