20100006005 CASE PRESENTATION

LONG CASE .

21 year old woman, working as a nurse in an outside hospital, residing at Nalgonda presented to casualty on 26/8/2021 with the chief complaints of

Fever since 4 months

Generalized weakness since 4 months

Cough since 1 month

Vomitings 2 episodes since 1 day

Unable to walk since 1 day

Unable to pass urine and stool since 1 day

H/O PRESENTING ILLNESS

She was born out of a non consanguinous marriage. She cried immediately after birth.

At birth - she was in the hospital for 2 - 3 days for jaundice later recovered and no complications were noted.

Her father works as a shop keeper and her mother works at a chaat bhandar. She has 2 elder sisters, both of her sisters works as the nursing staff.

She was apparently alright until 1 year back when she noticed swelling in her neck after for which she went for a checkup to a local hospital where she got diagnosed to be hypothyroid. She was started on Tab thyronorm 100mcg once daily.

Few months later she developed generalized weakness for which she paid a visit to a local hospital where in she was diagnosed with ? Iron deficiency anemia for which she used iron and vitamin supplementation for 2 days and stopped on her own.

4 months back she developed low grade fever for 1 week which was low grade ,nocturnal in variation, not associated with any night sweats and was relieved by medications. Since then she has been experiencing low grade fever intermittently. She started experiencing generalized weakness and loss of appetite.

She also tells us that she started experiencing extreme body pains to an extent that she stopped going to work.

Since 1 month she has been having cough with scanty, non blood tinged mucoid expectoration.

She paid a visit to a local hospital and received symptomatic treatment for a week.

1 day back she had 2 episodes of non projectile, non bilious,

non blood tinged Vomiting.

On 26th of this month, she suddenly fell off from her bed at 7am in the morning when she tried to get up from her bed. Her mother and father had to lift her up and put her on the bed. She was unable to raise her bilateral lower limbs. Though she was able to move her toes with difficulty. Few hours later she started experiencing tingling sensation in her bilateral lower limbs. They assumed it was due to her generalized weakness and loss of appetite so she wasn't taken to any hospital. She even didn't pass urine and stool since morning. By evening after noticing that their daughter couldn't get up from her bed her parents got alarmed and got to our hospital.

On further questioning:

She gave no complains of difficulty in combing her hair, no difficulty in mixing of food.

She had difficulty in getting up or turning/rolling in the bed

No H/o altered sensorium, loss of consciousness, seizures.

She gave no complaints of loss of smell, vision, diplopia or eye movements, squint , inability to close eyes

no difficulty in chewing, loss of sensation over the face,

No loss of taste, hearing , tinnitus ,vertigo, ear fullness

No difficulty in swallowing, nasal regurgitation ,nasal twang of voice

No difficulty in shrugging shoulders ,turning neck to one side.

No deviation of tongue on protrusion.

No H/o trauma ,injury .

No H/o recent vaccination or dog bite.

No history of any radiation exposure.

No history of chronic radicular back pain.

No history of arthralgia , photosensitivity.

No H/o unilateral or bilateral swelling of lower limbs

No H/o acute onset of breathlessness.

She says that she lost around 10kgs over the past 6 months

Past history:

No history similar episodes in past .

No significant surgical or medical history.

PERSONAL HISTORY:

Diet - mixed

Appetite - decreased since 4 months

Bowel and bladder - unable to pass

No addictions

FAMILY HISTORY : No significant family history.

Summary:

GENERAL EXAMINATION:

On presentation to us:

Patient was examined in well lit room in supine position ,

Thin built woman, poorly nourished ,

Conscious, cooperative , well oriented to time ,place ,person.

She had pallor

Her vitals were stable

Afebrile to touch ,

Blood pressure : 120/80 mmhg taken in supine , rightness brachial artery.

Pulse rate : 74/min right radial artery , rhythm and volume were normal, no radio radial delay or radio femoral delay,no apex pulse deficit , all peripheral pulses are felt.

Respiratory rate - 16 /min thoraco abdominal type.

GCS - 15/15

MMSE of 30/30

No raised JVP.

CRANIAL NERVES

CRANIAL NERVE	TEST	RIGHT	LEFT
I	Sense of smell i) Coffee	+	+
II	i) Visual acuity – Snellen Chart ii) Colour vision – Ishihara chart iii) Fundus	6/6 Normal Normal	6/6 Normal Normal
III, IV, VI	i) Extra-ocular movements ii) Pupil – Size iii) Direct Light Reflex iv) Consensual Light Reflex v) Accommodation Reflex vi) Ptosis vii) Nystagmus viii) Horners syndrome	full 3mm Present Present Present Absent Absent No	full 3mm Present Present Absent Absent No
V	i) Sensory -over face and buccal mucosa ii) Motor – masseter, temporalis, pterygoids iii) Reflex a. Corneal Reflex b. Conjunctival Reflex c. Jaw jerk	Normal Normal Present Present Present	Normal Normal Present Present Present
VII	i) Motor – nasolabial fold occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma ii) Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus iii) Reflex – Corneal Conjunctival iv) Secretomotor – Moistness of the eyes/tongue and buccal mucosa	Present Good Good Good Good Good Normal Normal Present Present Normal	Present Good Good Good Good Good Normal Normal Present Present Normal
VIII	i) Rinnes Test ii) Webers Test iii) Nystagmus	Positive Not lateralised Absent	Positive Absent
IX, X	i) Uvula, Palatal arches, and movements ii) Gag reflex iii) Palatal reflex	Centrally placed and symmetrical Present Present	Present Present
X1	i) trapezius ii) sternocleidomastoid	Good Good	Good Good
XII	i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side	Normal No No Normal	Normal No No Normal

Bulk - Right Left

Mid arm 18cm 18cm

Forearm 13cm 13cm

Mid thigh 26cm 26cm

Leg 18.5cm 18.5cm

Tone

UL Reduced bilaterally

LL Reduced bilaterally

Power

III – POWER

a. Neck muscles

b. Upper limbs

i) Shoulder

Flexion-Extension

Lateral Rotation-Medial Rotation

Abduction -Adduction

ii) Elbow

Flexion-Extension

iii) Wrist

Dorsi flexion-Palmar flexion

Abduction-Adduction

Pronation-Supination

iv) small muscles of hand

v) Hand grip

c. Lower limbs

i) Hip

Flexion-Extension

Abduction-Adduction

Lateral Rotation-Medial Rotation

ii) Knee

Flexion-Extension

iii) Ankle

Dorsi flexion-Plantar flexion

Inversion-Eversion

iv) Small muscles of foot

d. Trunk muscles

e. Beevor’s sign

Good

4+/5

Good

2/5

Weak

Good

4+/5

Good

2/5

Weak

LOCAL EXAMINATION

1)Neck

Flexion 5/5

Extension 5/5

2) Shoulder

Abduction -

RIGHT Left

Supraspinatus . 4+/5 4+/5

Deltoid . 4+/5 4+/5

Infraspinatus . 4+/5 4+/5

Lattismus dorsi . 4+/5 4+/5

Serratus anterior . 4+/5 4+/5

Pectoralis major . 4+/5 4+/5

Rhomboid. . 4+/5 4+/5

3) Elbow

Biceps . 4+/5 4+/5

Triceps . 4+/5 4+/5

Brachiradialis . 4+/5 4+/5

4) Wrist

Flexor carpi radialis . 4+/5 4+/5

Flexor carpi ulnaris . 4+/5 4+/5

Extensor carpi radialis longus . 4+/5 4+/5

Extensor carpi ulnaris longus . 4+/5 4+/5

Extensor digitorum . 4+/5 4+/5

5)Handgrip

Abductor pollicis longus 4+/5 4+/5

Abductor pollicis brevis 4+/5 4+/5

Extensor pollicis longus 4+/5 v 4+/5

Extensor pollicis brevis 4+/5 4+/5

Oppenens pollicis longus 4+/5 4+/5

Opponens pollicis brevis . 4+/5 4+/5 .

Adductor brevis . 4+/5 4+/5 .

Dorsal interossei . 4+/5 4+/5 .

Palmar interossei . 4+/5 4+/5 .

6) Trunk Abdomen

Able to roll but unable to get up from the bed on her own

7) Hips

RIGHT LEFT

iliopsoas 4-/5 4-/5

Adductor femoris 4-/5 4-/5

Abductor femoris 4-/5 4-/5

Gluteus maximus 4-/5 4-/5

Gluteus medius 4-/5 4-/5

8)KNEE

Internal rotators . 4-/5 4-/5

External rotators 4-/5 4-/5

Extension 4-/5 4-/5

Flexion 4-/5 4-/5

9)Ankle

Dorsiflexion . 4+/5 .4+/5

Plantar Flexion. . 4+/5 . 4+/5

External rotation . 4+/5 . 4+/5

Internal rotation . 4+/5 . 4+/5

Vibration 5.3 seconds 8seconds

Ankle. 6 seconds. 6seconds

Medial malleolus. 6seconds. 6seconds

TibiaL tuberosity. 6seconds. 06 seconds

Elbow 7seconds. 07 seconds

Crude touch Normal. Normal

Temperature able to perceive heat and cold

Fine touch. Normal normal.

Romberg sign. mild swaying to right

Proprioception. Decreased 3-4/10 9/10

Stereognosis good good

Tactile localisation. Normal normal.

Two point discrimination present present

UL 4+/5 4+/5

LL 2/5 2/5

Reflexes

B - -

T - -

S - -

K - -

A - -

P Extensor bilaterally

Abdominal reflex - Absent

SENSORY SYSTEM previous admission

TEST	RIGHT	LEFT
I – SPINOTHALAMIC 1. Crude touch 2. Pain 3. Temperature II – POSTERIOR COLUMN 1. Fine touch 2. Vibration 3. Position sense 4. Romberg’s sign III – CORTICAL 1. Two point discrimination 2. Tactile localisation 3. Graphaesthesia 4. Stereognosis	Reduced Reduced Reduced Reduced Reduced Lost Unable to perform Lost Lost Lost Normal	Reduced Reduced Reduced Reduced Reduced Lost Unable to perform Lost Lost Lost Normal

Priopioception lost upto the level of ankles

Vibration: Reduced in the lower limbs, more on the right side

Right Left

Great toe 3 secs 4 secs

Ankle 3 secs 8secs

Knee 6 secs 8secs

Wrist 10 secs 11 secs

Elbow 11 secs 12 secs

Fine touch - + +

Crude touch:

On right side she complained of reduced touch on her right thigh

Spinal Tenderness- present throughout all the levels of spine

Cerebellar signs - absent

No involuntary movements present.

Lungs - Reduced breath sounds bilaterally in all the lung fields

Cvs - S1,S2 +

Per Abdomen-

Bowel sounds +

Her weakness aggravated since yesterday

She also complains of neck stiffness

Neck stiffness-

Kernigs sign -

brudzinskis sign -

28/09/2021

Power is now 0/5 in both the lower limbs next day

Reflexes - Bilateral finger flexion + on Biceps and supinator examination

Lower limb reflexes absent

Abdominal reflex absent

Sensory system:

Vibration Reduced upto the level of hip joint ( lesser on the right side)

Proprioception absent upto the level of ankles

Couldn't appreciate fine and crude touch below the level of umbilicus

Extraocular muscles - normal

Pupils bilaterally reacting to light

All the other cranial nerves normal

Investigations:

Hemogram:

RBC: 4.09

WBC: 12300

Hb- 8.4

PLT- 4.8 lakh

Aptt- 32 sec

PT - 16 sec

INR. - 1.11

BT - 2 min

CT - 4 min

ESR - 90 mm in 1st hr

CUE:

Albumin- nil

Sugars- nil

Pus cells - 2 to 3

Epithelial cells - 2 to 3

Blood urea- 22 mg/dl

Serum creatinine - 0.6 mg/dl

TB- 0.70 mg/dl

DB. - 0.19 mg/dl

Na+ - 132 meq/lit

K+ - 3.4 meq/lit

Cl- : 94 meq/lit

ALP: 236 IU/lit

SGOT: 13 IU/LIT

SGPT: 10 IU/LIT

Serum protein: 6.5 gm/dl

Serum magnesium: 2.2 mg/dl

Serum calcium: 9.6 mg/dl

Serum albumin: 2.4 gm/dl

Covid-19- Negative

Peripheral smear- Microcytic hypochromic anemia with leucocytosis

MRI BRAIN IMPRESSION- Acute infarct involving the genu of the corpus callosum on the left side

Provisional diagnosis:

H/O PULMONARY KOCH'S

B/L PARAPLEGIA

probable differentials :

1) transverse myelitis ? non compressive etiology

2) amyotrophic lateral sclerosis

3) Multiple sclerosis (rare)

4) NMO spectrum diseases

5) GBS

5) Friedrichs ataxia ( very rare)

Investigations-

X ray on 14-09-2021

X ray on 20-09-2021

ECG-

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

Usg on 26-08-2021

Usg on 14-09-2021

2D ECHO-

MRI Findings-

Treatment -

On 28-07-2021:-

1) IV FLUIDS NS,RL@100ml/hr

2) Inj.Optineuron 1ampoule in 100ml NS IV OD

3) Inj.Zofer 4mg IV/TID

4) Tab.pcm 650 mg PO SOS

5) Inj.Neomol IV SOS if temp>101°f

6) Nebulization with Duolin and budecort 6th hrly

7) Syr.Ambroxol 5ml PO TID

8) TAB.Thynonorm 50 mcg PO OD

9) TAB.Ultracet PO QID

10) TAB.Ecosporin 75mg PO H/S

11) TAB.Atorvas 10 mg PO H/S

12) TAB.Clopidogrel 75 mg PO H/S

13) Protein powder 2 spoons in 100ml milk PO /BD

Plan of care at discharge-

1) Tab.Levipil 250 mg PO/BD

2) Tab.ATT 2tabs PO /OD BBF-8am

3) Tab.thyonorm 50 mcg PO OD - 8AM

4) Tab ecospirin 75mg PO/OD

5) Syr.cremaffin plus 15 ml /Po H/S

6) Tab Benadon 40mg/PO/OD

7)Tab.Hifenac MR/PO/SOS

8) Tab.Pan 40 mg/PO/OD - 8AM

9) Tab.Ultracet 1/2 tab PO/SOS.

10) Physiotherapy of neck

11) Air /water bed - position change 2nd hrly

12)Neosporin powder for bed sore

13) Protein powder in glass of water or milk PO TID

14) Egg whites 3 to 4 /day.

15)Tab wysolone 20 mg/PO/BD tapered within weeks

Advised attenders to get orthotic support.

On further follow up on 16/06/2023,

USG ABDOMEN - No sonological abnormality detected

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SHORT CASE I

A 50 year old Male came with chief complaints of abdominal distension since 4 days associated with shortness of breath since 3 days.

DAILY ROUTINE AND BIOPSYCHO SOCIAL HISTORY:

- He is a 50 year old gentlemen who stays with his mother, his wife and his son.

he had two elder daughters who got married at age of 18 years (elder daughter) and second daughter got married at age of 20 years.

- Before their marriage he used to work for annual income of around 8000-10000 at a farmer house who has many acres of land which are used for farming.

- Later after their marriage he stopped working at that farmer and started to farm his own 1 acre and also used to work in muncipal office where he used to wake up at early morning 5 am and used to clean roads ,schools , other government offices and comes to home by 9-10am and with friends of muncipal offfice he used to go near alcohol vending shop and used to buy 1 litre of sara(local alchol drink) which costs him around 150-200 rupees.

- this used to be his routine lifestyle for the last 10-12 years .

PRESENT ILLNESS:

- One fine day ,Around February 2023, an ASHA worker had visited the patient in his area for a routine check up and had noticed and mentioned to the patient about the yellowish discolouration of his eyes

- for which he got it checked at a local nearby hospital and was given conservative management for the same for which the symptoms were relieved . since then patient had stopped consuming these alcohol related drinks.

- Sometime in April 2023, patient then he developed distension of abdomen that was insidious in onset, gradually progressing associated with shortness of breath (grade 2 of MMRC)

-for which he was admitted into our hospital where he got treated conservatively along with a therapeutic ascitic tap that was done.

- Ever since then, he has stopped consuming alcohol and moved to a more vegetarian diet.

Presently, patient who is on regular medication who came with

- abdominal distension- insidious in onset, gradually progressive associated with Shortness of breath- of grade II type i.e, walks slower than usual and usually stops to catch his breath (MMRC).

- no h/o fever, cold, cough, chest pain, orthopnoea, PND

H/0 of yellowish discoloration of eyes 2 months back subsided, now started again since 4days

No h/0 of nausea and vomitings,

No h/0 of pain abdomen

No h/0 of decreased urine output

No h/0 of high coloured urine and clay coloured stools.

No history of blood transfusions

No bleeding manifestations.

No H/o usage of TB drugs or any other medication.

PAST HISTORY-

-No history of Hypertension, Diabetes Mellitus, CVA, Tuberculosis, Asthma.

- no past surgical history.

- no h/o allergies.

- During us admission 3 months back, an endoscopy was done i/v/o Oesophageal varices grade 3-4

https://youtu.be/0Q9LmL09i2s

PERSONAL HISTORY-

DIET- Presently a more vegetarian based diet

APPETITE- Normal

BOWEL AND BLADDER MOVEMENT- regular

SLEEP- adequate

HABITS- Stopped alcohol consumption 4 months ago. Otherwise was a chronic alcoholic for 20 years, namely consuming Sara, a country alcohol having about 25 to 45 % alcohol content with 100-120gm/day

FAMILY HISTORY- Insignificant

PROVIOSIONAL DIAGNOSIS:

Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension with no hepatic encephalopathy.

GENERAL PHYSICAL EXAMINATION-

- Well built and moderately nourished

- Weight : 60kgs

- Height : 164 cm

Pedal edema- Present (pitting type)

HEAD TO TOE examination:

Axillary hair loss seen

No parotid swelling

Palmar erythema absent

14.06.23 after paracentesis

Hyperpigmented patches seen on palm

Gynaecomastia present but non tender

Pale colour nails absent

Tremors absent

Spider naevi not seen

Petechiae, purpura not seen

GENERAL EXAMINATION

Patient is conscious, Oriented, Comfortable, Co-operative

afebrile

Pallor - present

Icterus - present

Cyanosis – negative

Clubbing – no

Pedal edema – bilateral, painless, pitting

No Significant lymphadenopathy

TROISIER’S SIGN - Negative

EXTERNAL MARKERS OF LIVER CELL FAILURE -

HEAD AND NECK– No alopecia, no bitots spots, no xanthelasma , subconjunctival hemorrhage, pallor +, icterus+, no medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, no parotid enlargement, bleeding gums

TRUNK – no spider nevi, no gynaecomastia, loss of pectoral/axillary hair present , no dilated veins, wasting, abdominal distension present , no caput medusae, no loss of pubic hair, no testicular atrophy, no scratch marks, purpura

UPPER LIMBS – left side dupuytrens contracture present , no bounding pulse, no clubbing, no flapping tremor, no palmar erythema, no pruritic marks

LOWER LIMBS – Pedal Edema present

NO BONY TENDERNESS, GUM HYPERTROPHY, LEUKEMIA CUTIS

VITAL SIGNS

PULSE: 82 bpm regular rhythm,normal volume, felt in all peripheral pulses,no radioradial/radiofemoral delay,no apex pulse deficit

BLOOD PRESSURE: 110/80 mm of Hg measured in the left Upper limb with the patient in sitting position

RESPIRATORY RATE: 16/min, regular abdominothoracic

TEMPERATURE: 98.2 F measured in the Axilla

SYSTEMIC EXAMINATION

EXAMINATION OF THE ORAL CAVITY- normal

ABDOMEN:

INSPECTION:

1. Shape – distended

2. Flanks –full

3. Umbilicus –everted, no nodules

4. Skin – no stretched, shiny, scars, sinuses, striae, nodules, scratch marks, puncture marks

5. No Dilated veins – front/back

6. Movements of the abdominal wall equal in all quadrants with respiration,

no visible gastric peristalsis,

7. Normal Hernial Orifices, no cough impulse

8. External genitalia - Normal

PALPATION:

Superficial Palpation – Tenderness, Warmth, Direction of Blood Flow in Veins

Deep Palpation

1. Liver : non-tender,

non-pulsatile

Right hypochondrium about 1 cms below the Right costal margin in the Mid clavicular line

Which moves with respiration and is

firm in consistency with a irregular surface

And a rounded edge

And I am not able to make out the upper border on Palpation

Probably an Enlarged liver

2. Spleen

no significant spleenomegaly

Palpation by Dipping in the case of Tense Ascites

Measurements - Abdominal Girth

Spino-Umbilical Distance

Distance between the Xiphisternum-Umbilicus and Umbilicus-Pubic Symphysis

External Genitalia - normal

PERCUSSION:

1. Shifting dullness - present

2. Percussion of Liver for Liver Span - Noat able to palpate

3. Tidal Percussion

AUSCULTATION:

1. Bowel sounds present – 10 to 15/min for small bowel, 3 to 5/min for large bowel

2. Bruit not heard

3. No Venous Hum

PER RECTAL EXAMINATION: stool stained

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:

S1, S2, no murmurs heard.

EXAMINATION OF RESPIRATORY SYSTEM:

No Added sounds

EXAMINATION OF NERVOUS SYSTEM:

no Flapping tremor, Peripheral Neuropathy

DIAGNOSIS

CHRONIC DECOMPENSATED LIVER DISEASE, CIRRHOSIS WITH PORTAL HYPERTENSION WITHOUT EVIDENCE OF HEPATIC ENCEPHALOPATHY

INVESTIGATIONS DONE :

On 13/06/2023-

Chest X-ray PA view

USG FINDINGS-

- Irregular and coarse echo texture of Liver

- Mild splenomegaly

- Gross Ascites (s/o chronic liver disease)

14/06/2023

Diagnostic Ascitic tap done of around 1000ml -

15/06/2023-

16/06/23-

Ascitic tap was done of around 500ml

TREATMENT:

Fluid restriction

Salt restriction

1)TAB LASIX 40 mg/BD

2)TAB ALDACTONE 50 mg /BD

3)TAB UDILIV 300 mg po /BD

4)Syrup LACTULOSE 20 ml po /TID

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SHORT CASE II

This is a case of a 45 year old female,resident of Nalgonda, technician by occupation came to the op with the chief complaints of

1) C/O multiple joint pains and swellings since 15 years

2) c/o generalised weakness and easy fatiguability since 6 months

History Of Presenting Illness:

Patient was born out of non consanguionus marriage and had 2 siblings .

at 15 yrs of age - Got married in 10th class (Non consanguinous marriage) Her partner was a from rich family where he doesnt used to go to job and used to drink alchol through out the day . and used to come back to home by evening and started to physically and mentally abuse our patient.

AT 18 YEARS - She gave birth to a healthy first male child through LSCS(No significant medical history was given for indication of LSCS)

AT 20 YEARS- Gave birth to a healthy baby girl through LSCS

She used to be a homemaker initially.

Due to her husband’s aggressive behaviour, she ingested pesticide which was seen by her sister.

immediately She was given some saltwater (which was home remedy to induce vomiting),induced vomitings and later she was shifted to Osmania hospital where she was admitted for 2 days and treated for ?organophosphorous poisoning.

Later she came away from her husband with her children for their education and

20 YEARS BACK (JAN 2003)-She joined as a technician in our hospital and also worked as a tailor

17 YEARS BACK(in 2006)-

One fine day patient initially observed left ankle swelling and left leg edema which initially resolved overnight but later didn’t seem to resolve with rest.

3-4 months later , she c/o bilateral lower limb edema about which she neglected due to her work stress

Gradually over a period of time , She also c/o pain in the large joints (ankle, knee, wrist ,elbow ,shoulder) and also neck pain .

There was no h/o small joint involvement

She used homeopathy medication but the pain didn’t seem to resolve

7 YEARS BACK (2016)

From 2006 to 2016, these joint symptoms gradually progressed in severity, now also involving several large joints (shoulders, elbows, knees ,wrist , ankle, lower backache) warranting several medical consults, where she was frequently prescribed pain killers and other homeopathic medications. The patient did not have any documentation of the pain killers he took in these 8 years. He reported that his symptoms alleviated with these drugs but he intermittently had worsening of same symptoms in the interim. The patient denied any history of skin rash, photosensitivity, nasal or oral ulcers, chest pain or abdominal pain, weakness in his limbs (such as difficulty in taking stairs or lifting heavy stones and nor any weakness in his distal aspects of limbs such as mixing food, buttoning his shirt or holding a glass or slipping of footwear), isolated single joint pain or edema, or a past history of kidney stones.she also does not have any history of difficulty in swallowing, altered bowel habits, pain in the pulp of his digits, or painful tearing, photophobia or visual loss. she also denied any history of gritty sensation in eyes or dryness of mouth.

Visited this hospital due to severe pain in the joints, and diagnosed to be having

anti CCP positive, ANA negative.

diagnosed with Rheumatoid arthritis and

She was started on Intraarticular triamcinolone and NSAIDs

During one of her routine checkups, she also c/o increase in her weight for which Thyroid profile is done and she was diagnosed with HYPOTHYROIDISM. She was kept on Tab. Thyronorm 25mcg PO/OD

5 YEARS BACK (2018)

She was also kept on Tab.Wysolone 5mg PO/OD(used it for 3 years) and Tab.Methotrexate (15mg) PO/OD

4 YEARS BACK(2017)

She was also kept on Hydrochloroquine (used it till 2022)

Also on Tab.Sulphasalazine 1000mg

2 YEARS BACK

Due to medication she c/o Recurrent epigastric pain and bloating like sensation where she underwent endoscopy and diagnosed with gastric ulceration since then patient is on PPI's.(Tab Rabeprazole 40mg once daily)

AUGUST 2022

During one of her routine investigations she was diagnosed to be having Type2 Diabetes Melkite’s for which she was kept on Tab.Metformin 500mg PO/OD

Past History

No significant past history.

PERSONAL HISTORY

DIET- Mixed

APETITE- Good

BOWEL AND BLADDER MOVEMENTS -Regular

SLEEP -Adequate

ADDICTIONS -none

MENSTRUAL HISTORY -

Age of Menarche -13 yrs

Periods -regular 5/28

No of pads-3/ days

Pain and clots absent

FAMILY HISTORY - No significant family history noted .

Social & Educational History

Married for 18 years with 2 children. Secondary education upto Class 10th in Telugu medium.

Localisation of Chronic Problem

This 45 year old woman has a 15 year history of bilaterally symmetrical progressive inflammatory polyarthritis. Features favouring an inflammatory pathology are -

Features of inflammation such as severe pain associated with edema of the joints and limitation of range of active movements
Early morning stiffness, lasting for more than 30 mins (for 1 hour in this patient)
Pain and edema of joints improving with activity and worsening with rest
Features of uncontrolled systemic inflammation such as fever, involuntary loss of weight associated with loss of appetite.
Swellings at joints and deformation of normal joint posture

Provisional Diagnosis - Bilaterally Symmetric Chronic Progressive Inflammatory erosive Peripheral Polyarthritis

Clinical Examination

Initial examination revealed, the patient was conscious, coherent and co-operative, lying in bed in supine position.

Vitals were taken in supine and sitting position -

Supine Position

Pulse - 92 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay. All peripheral pulses were normal.

Blood Pressure - 140/90 mmHg

Temperature - 98.3F

Respiratory Rate - 24 cycles per minute. Mildly acidotic + (with prolonged duration of expiration)

Sitting Position

Pulse - 96 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay.

Blood Pressure - 140/90 mmHg

Head to Toe General Examination

Ht-155cm

Wt-74 kgs

General Condition - Fair built and appears well nourished.

Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp.

Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. sclera of both eyes normal. Palpebral conjunctival pallor +. No icterus. No cyanosis.

General Head, Neck & ENT - No abnormalities. No lymph node enlargement.

Axial - No apparent spinal deformities

Fingers and Nails - No clubbing or cyanosis. Capillary refill time - 2 seconds.

Bilateral pitting type pedal edema +, extending upto middle of legs.

SYSTEMIC EXAMINATION:

MUSCULO SKELETAL SYSTEM:

Axial Skeleton

Inspection - No visibly apparent spinal deformities;

Palpation - Inspectory findings confirmed. No spine tenderness.

Movements - Atlanto-occipital - Flexion, extension and lateral flexion normal

Atlanto-axial - Rotation of head normal

Spinal Flexion, Spinal Extension, Lateral Flexion and Rotation are normal

Appendicular Skeleton - Upper Limbs (Positive Findings)

Shoulders (both sides) -

- Inspection - Attitude - Slightly flexed and internally rotated; Contour normal; No edema or erythema

- Palpation - no increase in temperature on both sides

- Range of Movements - No limitation of range of movements (flexion, extension, adduction, abduction, internal rotation and external rotation)

Elbows (both sides) -

- Inspection - Attitude - mid-flexion; alignment of elbow and forearm - normal; No Edema ; No scars or sinuses; no muscle wasting

- Palpation - All Inspectory findings are confirmed; No Raised temperature ; no Edema ; mild Wincing on touch + ; Fluctuation test negative ; 3 point bony relationship intact

- Range of Movements - No limitation.

Wrists (both sides) -

- Inspection - Attitude - Mild extension; no Radial deviation of wrists ; no edema ; no Redness ;

- Palpation - All Inspectory findings confirmed; no Temperature raise; no Wincing on touch ;

- Range of Movements - No limitation.

Hands (both sides) -

- Inspection - Attitude - No Palmar subluxation and Ulnar deviation of the MCP joints; No Swollen and Erythematous PIP joints; No swelling or redness of DIP joints; No apparent muscle wasting; Mild hyper-extension of PIP of thumbs; Pulp of fingers normal

- Palpation - All Inspectory findings are confirmed; No Temperature raise ; mild Wincing on palpation; Palpation of DIP joints is normal;

- Range of Movements - mild pain and mild limitation of active movements of flexion, extension and ulnar and radial deviation of MCP joints; mild pain and limitation of active and passive movements of flexion and extension at PIP joints. DIP joints normal.

Appendicular Skeleton - Lower Limbs (Positive Findings only)

Hip Joints (both sides)

- No Limitation of passive movements of flexion and extension (towards the end of range of motion);

Knee Joints (both sides)

- Inspection - Swelling and erythema + ; Attitude - flexion;

- Palpation - All Inspectory findings are confirmed;mild Raised temperature + ;

- Range of movements - mild pain and limitation of active and passive movements of flexion and extension and lateral and medial rotation;

Ankles (both sides)

- Moderate pain and limitation of active and passive movements of plantar flexion and dorsiflexion; Mild pain and limitation of movements of inversion and eversion.

- Palpation of Achilles tendon is normal.

Foot examination (both sides)

- Mild pain and limitation of passive movements of flexion and extension of MTP joints; great toe flexion and extension normal;

Other Systems Examination

Cardiovascular System - No abnormalities detected

Respiratory System - No abnormalities detected

Abdominal Exam - No abnormalities detected

Nervous System - No deficits detected

INVESTIGATIONS

CBP

Hb-9.8

TLC-8600

N/L/E/M/B-68/25/2/5/0

Platlets -4.5

MICROCYTIC HYPOCHROMIC ANAEMIA

FBS-106

PLBS-241

HbA1c-7.0

THYROID PROFILE

T3-1.06

T4-12.03

TSH-4.15

LIPID PROFILE

Total cholesterol-190

Triglycerides-238

HDL-39

LDL-118

VLDL-47.6

RFT

Urea-24

Creatinine -0.7

Uric acid-2.2

Calcium-9.3

Phosphorus -3.1

Sodium-135

Potassium-4.6

Chloride-101

LFT

Total bilirubin-0.60

Direct bilirubin -0-15

SGOT-22

SGPT-17

ALP-173

Total proteins-5.8

Albumin -3.5

A/G ratio-1.58

Left knee lateral view showing decreased joint space and erosive changes are noted.

Right knee lateral view

Right knee ap view

Left knee ap view decreased joint space with thinning of articular cartilage is seen

Right hand with wrist ap view

Left hand with wrist ap view

X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. scallop sign negative.

Left hand with wrist lateral view

Right hand with wrist lateral view

Left ankle lateral view

Right ankle lateral view decreased joint space with erosive changes are noted.

Left ankle ap view

Right ankle ap view

ECG:

Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal.

The patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis. Differential diagnosis for such conditions include -

Rheumatoid Arthritis (most likely)
Rheumatoid Arthritis with coexistent Gout
Psoriatic Arthritis
Enteropathic Arthritis
Reactive Arthritis
SLE

With Rheumatoid Arthritis being most likely, ACR/EULAR classification criteria can be applied for diagnosis -

This patient has >10 joints involved with multiple small joints involvement - 5 points; Symptom duration 10 years - 1 point; RA Factor - NEGATIVE; CRP elevated & ESR elevated- 1 point; Total Score - 7/10

This patient had a chronic history of symmetric small joint and then large joint inflammatory peripheral polyarthritis, With minor erosions notable in the PIP and MCP joints of both hands, classification criteria are diagnostic for Rheumatoid Arthritis.

No history of skin rash (psoriatic arthritis) or chronically altered bowl habits (enteropathic arthritis); No history of dysuria or burning pain during micturition or a history of severe burning pain in eyes with photophobia and excessive tearing or discharge (reactive arthritis) makes the other diagnoses unlikely.

Epidemiologically, SLE occurs more commonly in females at a ratio of 9:1, coupled with this, the absence of other features of SLE, such as alopecia, photosensitivity rash, nasal or oral ulcers, serositis, hemolytic anemia etc. makes this diagnosis very unlikely.

The absence of muscle weakness, muscle pain and the presence of destructive arthritis makes Polymyositis / MCTD extremely unlikely (Polymyositis usually causes nonerosive arthritis).

FINAL DIAGNOSIS:

45 YEAR OLD FEMALE WITH RHEUMATOID ARTHRITIS SINCE 15 YEARS WITH HYPOTHYROIDISM SINCE 7 YEARS AND DIABETES MELLITUS TYPE 2 SINCE 1 YEAR.

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GM PG FINAL YEAR UNIVERSITY PRACTICAL EXAMINATION