FINAL PRACTICAL EXAM LONG CASE.

 This is an online E log book to discuss our patient’s de-identified data shared after taking his/her/guardian’s signed informed consent.

A 50 year old female patient a resident of Nalgonda, home maker came to the OPD with chief complaints of pain and stiffness in several joints since 1 year.

HISTORY OF PRESENT ILLNESS:

She was apparently asymptomatic 10 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(MCP joints) of right hand with limitations of movements at the joints. 

Then within 6 months of onset the disease progressed to involve other joints of the right hand and left hand as well(wrist joint and elbow joint) 

Within 4 years of onset she started feeling pain in the joints of the feet and ankle joint. 

Since 3 months the pain became unbearable limiting  her activities

The pain was insidious in onset, slowly progressive dull aching type of pain, non radiating, associated with swelling, stiffness and limitations of movements in the involved joints.

Stiffness and pain was more in the first 1 hour of waking up and gradually improved on movement.

There are few exacerbations associated with fever.

• No deformities 
• No loss of weight.
• No involvement of distal interphalangeal joint
• No butterfly rash
• No abnormal jerky movements (chorea)

PAST HISTORY:

She has no similar complaints 10 years ago. 

No history of thyroid, Asthma, hypertension, diabetes 

DRUG HISTORY:

No known drug allergies 

MENSTRUAL HISTORY:

• Menarch: 13 years 
• Regular 29 day cycles 
• Menopause: 47 years 

FAMILY HISTORY:

No similar complaints

PERSONAL HISTORY : 

1. Diet: mixed 
2. Appetite: normal 
3. Bowel and bladder: regular 
4. Sleep: adequate 
5. No addictions 

General examination: 

patient is conscious coherent and cooperative 

Moderately built and nourished 

• No pallor
• No icterus 
• No cyanosis 
• No lymphadenopathy 
• No edema

VITALS:

1. Temperature: afebrile 
2. Blood pressure: 115/70
3. Respiratory rate: 15 CYCLES/MIN
4. Pulse rate: 76bpm

LOCAL EXAMINATION:

INSPECTION 

Skin : 

No pigmentation 

No scars 

No atrophic changes 

Nails: normal 

Soft tissues: swelling over the joints 

Deformities : no deformities 

PALPATION

Skin: warm

Sensations are preserved 

Soft tissues: no edema 

Joint capsule: mild swelling over the joint 

Tenderness over the joint (squeeze test)

Movements: 

Decreased range of movements at PIP, MCP, wrist, elbow, ankle joints 

All active and passive movements at the involved joints and painful. 

EXTRA ARTICULAR MANIFESTATIONS:

Eye: no ocular manifestations (episcleritis, scleritis, keratoconjuctivitis sicca)

Ear: no hearing loss

Muscle: no muscle atrophy 

GIT: no xerostomia, no parotid gland enlargement, no dysphasia 

No lymphadenopathy 

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM

Apex beat: 5th intercostal space medial to midclavicular line 

S1 and s2 heard 

JVP normal

Pedal edema: absent 

RESPIRATORY SYSTEM

Breath sounds: normal 

No additional breath sounds 

CENTRAL NERVOUS SYSTEM

cranial nerves intact 

Reflexes preserved

Sensations preserved 

Joint position sense: intact 

ABDOMEN

No abnormal findings found. 

DIFFERENTIAL DIAGNOSIS

1. Rheumatoid arthritis

2. Osteoarthritis

INVESTIGATIONS:

1. Complete blood picture 

2. ESR 

3. CRP

4. Rheumatoid factor 

5. Liver function tests 

6. Renal function tests 

7. Urine examination 

8. Antibodies 

9. X-ray 

X ray Findings: 

1. Decreased joint space 

2.osteoporosis 

3. Mild erosions 

Rheumatoid factor: positive. 

Anti CCP antibodies: negative. 

CRP: positive. 

ESR: elevated. 

PROVISIONAL DIAGNOSIS:

                                            RHEUMATOID ARTHRITIS. 

TREATMENT:

1. Methyl prednisolone 

2. Hydrocortisone Sodium. 

3. Tramadol hydrochloride 

FINAL PRACTICAL EXAM SHORT CASE.

 This is an online E log book to discuss our patient’s de-identified data shared after taking his/her/guardian’s signed informed consent. 

A 35 year old male patient, resident of ramchandrapuram, works as a daily wage labourer, a chronic smoker (1 pack of beedi every 2 days) and a chronic alcoholic (90ml daily) since 20 years presented with a 3 month history of painless papules with erythema that started initially over the face then gradually extended to upper limbs, lower limbs and trunk. 

• No hypodense lesions 
• No fever 
• No pus
• No loss of sensations
• No genital lesions 

Patient got over the counter topical cream, soap and some oral drugs from a nearby medical shop.  

He used them for 2 months, few lesions regressed but a few persisted on his nose, ear lobe, hands, legs and trunk.

14 days ago, the patient developed blackish skin discolouration over hands and feet with skin peeling, cracking, ulcer formation associated with burning sensation and erythema all over the body. 

No new lesions were noted. 

Since 4 days, the patient developed high grade fever associated with chills and rigors.

Associated with Loss of appetite.  

There is no history of similar complaints in the past.

EXAMINATION:

• Face: loss of eyebrows, thickened earlobe
• Oral cavity: dark erythematous lesions on the palate
• Multiple lesions of different sizes with ill defined erythematous borders and pale hypopigmented centre with peeling and raw areas are seen on trunk, limbs and face
• Scaly hyperpigmented plaques with fissures noted involving the feet Extending  from the sole to the dorsal aspect of the foot

DIAGNOSIS:

Leprosy (Hansen's Disease.)