45 yrs old female with wrist and ankle joint pains since 4 years.
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Name: B.Pavithra(intern)
Roll no:09
CASE:Ip no:202315454
45 years old female came with C/O right and left wrist and ankle joint pain since 4 years
C/O neck pain since 4 years
C/O generalised weakness and difficulty in lifting weights since 4 years
HOPI:
Patient was apparently asymptomatic 4 years back and then patient developed joint pains such as wrist and ankle joint pains which is insidious in onset gradually progressive,dull aching type of a pain, associated with early morning stiffness lasts for 2 hours
Pain aggravates relatively at end of the day, associated with fever- low grade not associated with chills and rigor on and off since 4 years
Patient also complaints of small joint pains such as metacarpo phalyngeal joints and proximal inter phalyngeal joints of both the upper limbs
C/O pain in the back of the neck which is insidious in onset gradually progressive,dull aching type of pain, radiating to the occipital region and shoulder since 4 years.
C/O tingling sensation of both the soles since 2 years
C/O lower back ache on and off since 4 years
No h/o large joints involvement like knee,hip,elbow and shoulder joints.
No h/o any trauma
No h/o nausea and vomiting.
No h/o sob,cold,cough,chest pain and pedal edema
No h/o burning micturation and decreased urine output.
Past history
N/K/C/O DM, HTN, TB, Asthma, epilepsy, CVA,CAD, thyroid disorders
H/O hysterectomy done 20 years back.
Personal H/O
Diet: mixed
Appetite : normal
Bowel: constipation on and off
Bladder: regular
Sleep: adequate
Habits: occasionally drinks toddy since 12 years stopped 4 years back
Family H/O:not significant
Menstural H/O:
AOM: 13 years
15/30 cycles before.
Hysterectomy done 20 years back
General examination
Patient is Conscious, coherent, cooperative, moderately built and moderately nourished
No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and bilateral pedal edema.
VITALS
temp: 98.6F
PR: 84bpm
RR:16cpm
BP:120/80mmhg
SpO2: 98 @ RA
GRBS: 134mg/dl
Local examination:
On/I:No redness,No swelling over the joints
On/p:No local raise of temperature.
Joint line tenderness is present in right and left wrist joints,MCP joint(more in 1st,2nd and 3rd) ,PIP joints and both the ankle joints and metatarsophalyngeal joint.
CVS:S1S2 hears, no murmurs
RS:BAE+ , NVBS +
P/A: soft, no. Tender
CNS: NAD
Investigations:
Serology: ON 8/4/23
Treatment:
Tab.Naproxen 250 mg po/bd
Tab.pantop 40mg po/od bbg
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