45 year old female with poly arthritis

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45 year old female currently working as ECG technician and previously worked also a tailor ,hailing from Nalgonda with the chief complaints of multiple joint pains and swellings since 17years

HOPI:

Patient was apparently asymptomatic 17years ago and then developed multiple joint pains,Started with left ankle severe pain and swelling,Gradually progressive ,involving multiple joints ,bilaterally symmetrical,involving ankle joints,knee,hips,shoulder ,elbows to currently involving wrist ,ankle pain still present .History of neck pain 5-6years ago subsided now,3days back history of pain during chewing on lateral cheek with swelling on both sides, relieved after 1day.Pains Relived transiently with pain killers.

Pain Relieving on activity Morning stiffness lasting 20-30ki minutes.No h/o any Deformities.

No h/o any fever,Oral ulcers,facial rash,photosensitivity,breathing difficulty,tingling numbness of limbs or weakness of limbs,bleeding manifestations 

PAST HISTORY:

Hypothyroidism diagnosed 10YEARS ago (visited hospital in view of weight gain)

Epigastric pain—>Gastric ulcer detected 2years ago

Diabetes incidentally detected 1year ago

Diagnosed to be having Seronegative Rheumatoid arthritis 15years ago (Anti CCP,ANA negative,CRP+)

H/o ?Insecticide poisoning 20years ago managed conservatively.

No H/o Asthma,COPD,TB,DM,HTN,CAD,Epilepsy

PERSONAL HISTORY:

Mixed diet

Appetite good

Bowel and bladder habits regular

Sleep adequate

No addictions

H/o weight gain 60->75kgs over 15years

Sleep adequate

No Food allergy

FAMILY HISTORY:

No significant family history

MENSTRUAL HISTORY:

Age of menarche-13years,5/28,no clots,normal flow

OBSTETRIC HISTORY:

P2L2A0

2children ,by LSCS

Last child birth:20years ago

1st child -Male

2nd -female

TREATMENT HISTORY:

Tab WYSOLONE 5mg OD used for 3years,5years ago

Tab Methotrexate 15mg once weekly used 5 years ago

Tab HCQ started 4 years Ago and used for 3 years

Tab Sulphasalazine 1000mg started 4years 

Tab Metformin 500mg PO OD

Tab Pantoprazole 40mg OD

Provisional diagnosis:Bilaterally symmetrical chronic progressive inflammatory peripheral polyarthritis 

EXAMINATION:

Patient is conscious,coherent and cooperative

Well built,well nourished

Height :155cms

Weight:74kgs

BMI:

VITALS:

Pulse:96bpm ,regular,normal volume and character,condition of vessel wall,no RR or RF delay

BP:140/80mmhg in right arm in supine position

Temp:Afebrile

RR:24cpm

GENERAL PHYSICAL EXAMINATION:

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema-Bilateral pitting type of pedal edema upto lower 3rd of legs

Other head to toe findings:

No scarring or non scarring alopecia 

Eyes normal

Skin ,Nails normal

Oral cavity normal

Pictures showing ankle swelling

LOCOMOTOR SYSTEM EXAMINATION:

1.PIP :Normal

2.DIP:Normal

3.MCP:Normal

4.Carpo metacarpal:Mild Tenderness + over 1st 2 carpometacarpal joints on both sides

5.Wrist :normal on inspection ,palpation and normal range of movements

6.Elbow:placed in mid flexion,normal alignment of arm and forearm,no muscle wasting,no tenderness,3point bony relation intact,ROM normal

7.Shoulder:

Slightly flexed internally rotated,normal contour,no edema or erythema,no increase in local temperature,Range of movements normal,Overhead abduction slightly painful

8.Acromioclavicular: Normal

9.Sternoclavicular:Normal

10.Temporo Mandibular joint:

Tenderness+,chewing movements normal,mild swelling +

11.Hip joint

Normal on inspection,palpation and normal range of flexion and extension

12.Knee joint 

Inspection:swelling present ,in flexion attitude

ROM:

13.Ankle joint

Tenderness on plantar and dorsi flexion+

Painful restriction of motion(flexion ,extension,inversion and eversion)

Achilles tendon palpation normal

14.Subtalar joint

Tenderness +,Swelling+

15.small joints of foot

MTP:Normal

Great toe:Normal

Examination of Spine:

Cervical spine:

Atlanto axial joint -normal neck flexion and extension

Atlanto occipital joint -normal neck rotation

Thoracolumbar spine : normal on inspection ,palpation

Sacroiliac joint:No tenderness,Schobers test negative

Examination of Respiratory system,Cardiovascular system,CNS,Per abdomen -Normal

PROVISIONAL DIAGNOSIS:

Bilaterally symmetrical chronic progressive peripheral polyarthritis

DD:

1.Rheumatoid arthritis

2.Sero negative arthritis-?Reactive,?Psoriatic 

3.Connective tissue diseases,SLE

ACR/EULAR criteria:

Number of joints involved-Multiple small and large joints:5points

Symptoms >6weeks:1 point

RA factor negative:0 points

CRP ESR elevated :1point

Total 7/10

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

RA factor:Negative

Anti CCP :Positive

X ray hands:osteopenia and erosions of MCP and PIP joints,Ankle

Decreased joint space in bilateral knee joint

Final diagnosis:Bilateral symmetrical erosive polyarthritis -Rheumatoid arthritis since 15years with hypothyroidism since 7 years and diabetes mellitus since 1 year