Short case final exam

1601006064

This is my short case where a 

 50 year old female came to the OPD with  

CHIEF COMPLAINTS-

Pain 

Stiffness in several joints since one year 

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 10 years ago thent 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 

No deformities 

No loss of weight 

PAST HISTORY-

She has no similar complaints 10 years ago 

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

MEDICAL HISTORY- 

She has no similar complaints 8 years ago. 

No history of thyroid, Asthma, hypertension, diabetes 

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

No 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

Apex beat - 5th intercostal space lateral 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 

Xray

PROVISIONAL DIAGNOSIS:

     RHEUMATOID ARTHRITIS

TREATMENT

1.Prednisolone

2.Hydrocortisone sodium

3. Tramadol

Final Exam Long case : Fibrosis

H.no : 1601006064

This is an E log to discuss our patient de- identified health data shared after taking his/her consent 

Consent Taken 

A 51 year old male patient resident of Miryalguda , farmer by occupation ,presented with a chief complaint of  

1. Fever  since 10 days 

2. Cough  with sputum since 10 days 

3. Shortness of breath since 7 days 

History of present illness

Patient was apparently asymptomatic 10 days back then developed following symptoms 

Fever which was insidious in onset and it was not  associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication 

He then developed Expectorate Cough which  gradually progressed more during the nights followed a similar  diurnal pattern  .The sputum was scanty and yellow which was non foul smelling

Cough was associated with Chest pain  which was non radiating in nature and aggrevated on lying down relieved on sitting upright 

He later developed gradually Dyspnea which went on to interfere his daily activities (indicating MMRC Grade 3 / 4 ) and eventually progressed  to orthopnea 

No history of wheeze 

Past history 

No history of 

Asthma 

Diabetes Mellitus 

Hypertension 

Epilepsy 

Known history of COPD 

Tb 5 yrs back, medication was taken for 2 months and stopped later on as the symptoms subsided

Family history

Not relevant 

Personal history 

Sleep: disturbed

Bowel and bladder regular 

Appetite: normal

Diet: Mixed

No food or drug allergies 

Addictions : smoking  since 40 yrs ( 10 cigarettes a day )

      Smoking index 400

      Alcohol  since 40 yrs  

Differential Diagnosis

 TB 

Exacerbated COPD

Fibrotic lung disease

Pneumonia

Examination 

 Patient was conscious coherent and cooperative 

Seems to be undernourished 

Vitals 

Pulse

• 82 bpm
• Regular
• Normal volume 

Bp 100/70 mm hg

Respiratory rate 29 cpm 

On physical examination 

Pallor present

Icterus absent 

Cynosis absent 

Clubbing absent 

Lymphadenopathy absent 

Edema absent 

Systemic examination 

Respiratory 

Upper respiratory tract examination 

• Nostrils : Normal
• Nasal septum: No deviated nasal septum
• Nasal polyps: No nasal polyps
• Tonsils :No enlarged tonsils
• Posterior pharyngeal wall appears to be normal

Inspection 

• Shape and symmetry :Elliptical and symmetrical 
• Spine: central
• Trachea :Appears to be central

Respiratory movements   decreased on both sides

Breathing pattern was Abdomino-Thorasic 

No visible pulsations 

No visible scars or sinuses

Palpation

Spine is central

Trachea  is central

Dimensions AP 16.5

                    Transverse 23.5 

Chest expansion was equal on both the sides

Vocal fremitus was increased on left infra clavicular and mammary region

Apex beat was felt on 5 th intercostal space medial to MCL

Percussion 

On percussion dull note was heard on 

• Left infra clavicular
• Left  mammary 

Auscultation

Decreased breath sounds 

There was an Increased  vocal resonance on left infra clavicular and mammary ( bronchophony and whispering pectoriloquy)

 No other added sounds heard 

Cvs 

Normal S1 S2 heard 

No murmurs

No jugular venous distension

Apex beat felt on 5 th intercoastal space 

CNS

No focal deficits seen

Diagnosis Fibrosis in the left apical region probably due to  improperly managed tuberculosis or exacerbated COPD