45 year old male with rheumatoid arthritis

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints:

Pain in wrists and ankles since 4 years

Neck pain since 4 years

Headache since 2 years 

History of presenting illness :

Patient was apparently asymptomatic 4 years ago then she developed pain firstly in left ankle followed by left wrist ,neck , right wrist joints,PIP , metacarpophalengeal joints are also  involved in  right hand,insidious in onset gradually progressive aggrevated by work and relived on medication.

Pain is confined to joint .

H/O pain in neck which radiated to shoulders and relieved on medication.

No h/o myalgia

No h/ o trauma

No h/o swelling,deformity

History of morning stiffness and lasts  for 2 hours .

Generalised weakness is present

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 micturition,decreased urinary output

No h/o weight loss,loss of appetite , sweating.

No h/o conjuctivitis ,skin rash,ulcers

No h/o chest pain,palpitations,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 relevant 

General Examination:

Patient is conscious, coherent and co -operative 

Pallor -absent 

Icterus- absent 

Clubbing - absent 

Cyanosis - absent 

lymphadenopathy - absent

Edema - absent 

Temperature - 98.3 ° F

BP- 120/80 mm hg

PR - 73bpm

RR - 15cpm 

Local examination:

Inspection 

No redness, no swelling,no deformity

Palpation 

No local rise of temperature 

Tenderness over joints on palpation

Eular criteria 

4 large joints -3 

4 small joints -3

Serology - high positive RF - 1 

Abnormal CRP - 1 

Duration of symptoms >1 week .

Total -8/10.

Movements:

Mild restriction of movement in left ankle and left wrist, MCPs

Pain is associated with movement 

Gait is normal.

Respiratory System 

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

Apex beat is 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 :

Normal vesicular breath sounds heard.

Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins.

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

Auscultation-

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

Central nervous system:

Conscious

Normal speech.

No neurological deficit found.  

Provisional Diagnosis: 

Rheumatoid Arthritis .