State Medical and Pharmaceutical University,, Nicolae Testemitanu, USMF

History and Examination of Rheumatological case

Professor: Eugen Russu

From: Baher Krayem Gr. 1540

Chisinau 2011

Case History

Patient Name: Odainic Aliona Age: 42, Birthday: 2/11/1969

Main Complaint: Pain in knees, tibia and sacral region that started two weeks before hospitalization.

Current Disease: The patient describes pain in the right knee and the sacral region that is characterized by: T (Timing) = The pain is intense during the first hours of the morning, the pain is episodic and not constant and lasts about half an hour. It wakes the patient during the night. The pain generally for one week every 2-3 months, but in this time the pain lasted more than two weeks. S (Severity) = At the beginning of the day the patient grades the pain as 8/10 but at night the pain reached the levels of 10/10. R (Radiation) = The pain is located in the sacral region, and in the knees, and radiates downwards to the ankle. Q (Quality) = The pain is described as deep aching pain. P (Palliative/Provocative) = Ibubrefen releifs the pain. Meloxicam also. When the weather is cold the pain usually is increased. Additional symptoms: Morning stiffness that lasts 20-30 minutes every day. Headache also is associated with the pain. Cold sweats. The patient says that NO diarrhea, nausea, or vomiting is present. (to exclude GIT infection).

Patient History: The patient started to suffer from pain since the year 2002. At the year 2009 she had tonsillectomy, due to the detection of Chlamydia infection. She declines any Rheumatoid Arthritis during childhood. Her mother suffered from RA. She suffers from hypotension (thats what she claims). She had also Hepatitis B (after dental treatment), but she was treated and fully recovered (according to her version). She doesnt have Tuberculosis, Diabetes, or any cardiovascular disease. She says that she doesnt and didnt had any STD in the past. She had natural abortion before. No history of trauma.

Habits and Allergy: Non smoker. She drinks only occasionally. She drinks coffee a lot. She does physical activity (Aerobics) 2 times a week. The aerobics doesnt affect the pain. She has allergy to Cephalosporins.

Social History: She works at a pharmacy; she is married with 2 kids. Stress is present at work and at home and usually it increases the pain.

Medical Treatment: Drug Ibubrefen Omeprazole Steroids Antibiotics Dose 200 mg * 2 times/day 50 mg * 1 time/day One injection every year in the sacral region She is not treated with Abs

Physical examination: Musculoskeletal: Inspection, palpation, movement and tone levels were examined in the various joints and muscular system in the body. Pain is present in the right knee, sacral region and the tibia. Swelling is present at the right knee, wrist, sacral region and ankle. Tenderness is present at the knee, and sacral region. Local edema is present in the left wrist, left knee more than the right knee, and left ankle. Redness is present in the mentioned joints. Heat is present also. There is slight limitation in motion and activity. Normal muscle tone. No atrophy is present. No deformity.

GENERAL APPEARANCE: (include general mental status) 42 y/o female who is awake and alert and who appears healthy and looks her stated age VITALS Temperature: 37.5 C oral Blood Pressure: R Arm/cuff (Systolic)- 120/70 R Arm/Auscultation- 126/70 L Arm/cuff (Systolic)- 122/70 L Arm/Auscultation- 126/70 Heart Rate by radial pulse palpation: 80 beats/minute

Respiration Rate: 14 breaths/minute

HEENT Head: Configuration- normocephalic Hair- normal texture Scalp- lesions, tenderness Eyes: Sclera- white Conjunctiva- pink Ears: External Ear- No lesions, masses, tenderness Auditory Canal- normal Eardrum- TMs gray, translucent, with normal light reflex Nose: Color- pink , No discharge Throat and Mouth: Teeth: Present and in good dentition Tongue: No lesions Gums and Mucosa: No swelling, bleeding, infection Pharynx and Tonsillar Fossa: normal

NECK Active ROM: nornal flexion, extension, lateral rotation and tilting Trachea: midline, mobile Thyroid: non-palpable or palpable, normal size & consistency, No lesions Suprasternal Notch: No pulsation

HEART

Neck Veins- no JVD at 45 Carotid Arteries: Palpation (Amplitude and Contour)- normal upstroke & amplitude bilaterally Auscultation: No bruits Precordium: Inspection- No lifts or heaves - PMI not visible Palpation- No parasternal impulses, No thrills PMI- palpable in 5th ICS Auscultation: S1- heard best at apex, normal intensity S2- heard best at base, nl splitting, A2 > P2 Extra Sounds- No S3, S4 Murmurs- No murmurs

THORAX & BACK Observation: symmetrical expansion with respiration Percussion: No spinal tenderness, No CVA (costovertebral angle) tenderness

LUNGS Percussion and Palpation of Lung Fields- normal resonant percussion Auscultation- clear, nromal vesicular breath sounds

ABDOMEN Observation: scaphoid No scars, striae Auscultation: normal bowel sounds, No bruits

Palpation: Superficial- No tenderness, masses, guarding Deep- No tenderness, masses Liver: Palpation- liver edge not palpable Percussion - Size- ~10 cm in R midclavicular line Spleen: Palpation- non palpable Kidneys: Left- non palpable Right- non palpable

SKIN: normal, No lesions

LYMPH NODES Neck: Submental- not palpable Submandibular- not palpable Anterior and Posterior Cervical- not palpable Pre and Post Auricular- not palpable Suboccipital- not palpable Supraclavicular- not palpable Axillary: Central Axillary- not palpable Pectoral- not palpable Subscapular- not palpable Lateral Axillary- not palpable Epitrochlear: not palpable Superficial Inguinal (horizontal and vertical): not palpable

NEUROLOGIC Mental Status: Awake & Alert; oriented to person, place & time. Cranial Nerves: II: Visual Acuity- 6/6, both eyes Visual Fields- intact in all fields II and III: Pupillary Reaction to Light- direct & consensual normal Accommodation- normal III, IV, VI: EOM- intact V: Light Touch Face- normal in all 3 divisions of V VII: Wrinkle Forehead, Close Eyes, Show Teeth- normal VIII: Hearing- normal by rough testing X: Cough- normal XI: Shrug Shoulders and check sternocleidomastoid muscles - normal XII: Protrude Tongue- midline protrusion Motor System: Normal tone Pathological - Plantar Reflex- none Coordination: Gait and Balance- normal Finger to Nose- normal Rapid finger movements- normal Tandem Walking- normal Romberg- negative

Laboratory Tests: The patient is sero-negative for Rheumatic factor. Hb = 12.4 RBC = 4.2 WBC= 5.9 ESR = 11 Complete blood count is normal. Biochemical test: Urea = 3.6 Creatinine = 0.7 Bilirubin = 16 Glucose = 3.9 Cholesterol = 5.9 Triglycerids = 0.69 K = 4.4 Na = 142

Diagnosis: Sero-negative Spondyloarthritis Reactive Arthritis. Oligoarthritis. Asymmetric Sacroilitis X-ray stage II. Functional disability 0-1. Although she excludes any urinary, diarrheal illness or STD (according to her story), a Chlamydia infection was discovered and this infection probably led to the reactive arthritis. The presentation of the patient showed unilateral involvement of the joints which is typical for reactive arthritis. There is involvement of inflammatory process, asymmetric oligoarticular joint involvement, the joints that are affected are large, weight bearing joints (knees and joints) with spinal affection.

Treatment: We should administer antibiotics: Doxycycline - 200 mg / day (Tetracycline) Or Clarithromycin - 1 g / day (Macrolide) Azithromycin - 500 mg - first day, after THEN 250 mg / day - 6 days (Macrolide) Roxithromycin - 300 mg / day (Macrolide) Or Ciprofloxacin 1 g/ day (Quinolones) Ofloxacin 400 mg/ day (Quinolones) Lomefloxacin 400 mg/ day (Quinolones) Perfloxacin 800 mg/ day (Quinolones)

We should also administer non steroidal anti inflammatory drugs, like: Diclofenac (75-150 mg) or

Meloxicam (7,5-15 mg) or Nimesulid (100-200 mg) or Ibuprofen (800 1600 mg) or Flurbiprofen (100 200 mg)

The use of Steroids is also appropriate in this condition: These agents can be used as either intra-articular injection or systemic therapy. Prednisone 0.5-1 mg/kg/d can be used initially and tapered according to response.

The use of DMARDS: Clinical experience with these so-called disease-modifying antirheumatic drugs (DMARDs) has been mostly in rheumatoid arthritis and in psoriatic arthritis. DMARDs have also been used in reactive arthritis, although their disease-modifying effects in the reactive arthritis setting are uncertain.

In addition Sulfasalazine may be beneficial in some patients. Sulfasalazine (2-3 gr per day) is widely used in all seronegative spondylitis.