41year female with RA- Short case
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Chief complaints:
Multiple joint pains since 7 years.
History of present illness :
Patient was a Taylor in the medical institute, her daily routine was to stitch the clothes with the help of machine from 9am to 4 pm in the medical institute.
She was apparently normal 7 years back , then developed pain in the right proximal interphalangeal joints association with stiffness in the early morning for about 1 hour and which gradually relieved after 2 hours of getting from the bed.Her early morning stiffness was severe in such a way that she used to take the help of his husband while getting up from the bed .
After few days she developed pain in the left proximal interphalangeal joints, which gradually progressed to wrist joint , elbow , ankle and meta tarsophalangeal joint.
No history of hair loss, oral ulcerations ,rash over the face.
No history of thickening of the skin.
No history of cough and shortness of breath.
Past history:
No significant past history.
Family History:
No significant family history.
General examination:
Examination:
Pulse Rate: 80 beats per minute
Blood Pressure: 100/60 mmhg
Respiratory Rate: 22 cycles per minute
Temperature: 98.6 F
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
General Examination:
Hair:
Normal hair distribution.
Eyes:
No erythema noted on conjunctiva .
Oral Cavity:
No mucosal ulcers
Nails:
No nail pitting, onycholysis, onychodystrophy
Skin:
No rash , ulcers over the skin, scaly lesions, dryness of skin, thickening of skin, no rash on sun exposed areas of the skin, no subcutaneous nodules.
Spine:
No spinal deformity
Musculoskeletal examination: ( positive findings)
Tenderness noted in the MCP joints of both fingers
Right Little finger: Boutonniere deformity
Left little finger: Swan neck deformity.
Boutonniere deformity of little finger
Investigations:
X ray both hands including wrist joints:
X ray both feet :
Chest x ray :
Bilateral reticulonodular opacities noted in both lungs
Respiratory System: No abnormality detected
Cardiovascular System: No abnormality detected
Abdomen: No abnormalities detected
Nervous System: No abnormalities detected
Investigations:
CUE -
ALBUMIN - NIL
SUGAR - NIL
PUS CELLS -NIL
EPITHELIAL CELLS - NIL
CBP -
HB - 12.0
TLC - 9,000
MCV - 82.1
PLATELETS - 3.02 LAKHS
NCNC
RBS - 106
LFT -
TB - 0.60
DB - 0.19
AST - 15
ALT - 212
ALP - 136
TP - 6.4
RFT -
UREA - 14
CREATININE - 0.8
URIC ACID - 3.8
Ca+ - 9.4
Phosphate - 2.6
Na + - 143
K+ - 3.7
Cl - 105
Other investigations :
C reactive protein - 2.4mg/dl.( Reference range -0.6mg/dl)
RA factor - Positive (96IU/ML) .
ESR - 33mm/1st hour.
Provisional Diagnosis:
Multiple symmetrical polyarthritis with chronic duration of around 7 years and with signs of inflammation, involving PIP joints and MCP joints with sparing of DIP joints - Rheumatoid Arthitis
with no other system involvement.
Treatment:
1) Tab Methotrexate 10 mg/ PO/weekly once .
2) Tab Folic acid 5mg / PO/weekly once.
3) Tab HCQ( Hydroxy chloroquine 200mg)/PO/ Once daily.
4) Tab Naproxen 250mg /PO/SOS.
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