A 45 year old female came to opd with complaints of pain in wrists and ankles since 4 years


Chief complaints 

Pain in wrists ( bilateral) and ankles since 4 years

Neck pain since 4 years

Headache since 2 years


Hopi

Patient was apparently asymptomatic back then she developed pain since 4yrs starting from left ankle first then left wrist , neck, right wrist ,PIP , metacarpophalengeal joints are involved .insidious in onset gradually progressive aggrevated by work and relived on medication .pain is confinedto joint

No h/o myalgia

No h/ o trauma

No swelling,deformity

History of morning stiffness continued for 2 hrs

Generalised weakness is present

History of neck pain since 4 years insidious in onset gradually progressive radiating to both shoulders relieved on medication 

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 micturation,decreased urinary output

No h/o weight loss,loss of appetite

No h/o conjuctivitis,skin rash,ulcers

No h/o chestpain,palpitation,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 significant

GENERAL EXAMINATION:

Patient is c/c/c


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


Temp-Afebrile 


BP- 120/80 mm hg


PR - 73bpm


RR - 15cpm


Local examination:


Inspection 

No redness, no swelling,no deformity 

No. Joints involved=

Left side= wrist , ankle, 1 st and 3 rd MCP

Right side= ankle ,wrist , 1st, 2nd MCP


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



R/S - 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

Apical impulse - 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:


Vesicular breath sounds normal heard


Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

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

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


Central nervous system:

Conscious

Normal speech.

No neurological deficit found.





https://youtube.com/shorts/zh4Rd-bDPdU?feature=share


Provisional diagnosis:

Rheumatoid arthritis under evaluation 


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