120 McArthur Highway, Valenzuela City

Department of Family Medicine and Community Health

Clinical History

General Data:
This is a case of Aida Amojilar, 53 years old, female, born on January 13, 1963 at Manila, married, Roman Catholic, Filipino,
currently residing at Barangay Sitio Bitik, Valenzuela City, second time to sought consult at our health center on January 11, 2016.
Chief complaint: Pain on left wrist and forearm
History of present illness
Five days prior to consult, patient experienced pain on her left wrist and forearm, described as sharp in character, nonradiating, with a severity of 5/10, aggravated by movement, intermittent and not relieved by rest. It was not associated with any other
symptoms such as limitation of movement, morning stiffness, erythematous, swelling and warm to touch. No history of trauma noted.
No medications taken to alleviate the pain and no consult done. On the interim, there is persistence of the above symptom with the
same intensity and character, with no associated symptoms, no consult and no medications taken, until few hours prior to consult, the
above symptom, now increase in severity from 5/10 to 7/10 but with the same character, hence sought consult.
Past Medical History:
Patient cannot recall the childhood immunization she had received. Patient claimed to have childhood illnesses, such as
measles, mumps and chickenpox. Patient denies of any adult immunization, such as hepatitis, flu and pneumonia vaccine. Patient
denies of any illnesses, such as hypertension, diabetes, hepatitis, cancer, asthma, liver diseases, kidney diseases, pulmonary
tuberculosis and pneumonia. No allergy on foods and medications. Patient was previously admitted at Jose Reyes on 1970 for three
months due to burn on both legs. Patient had history of blood transfusion but unrecalled number of bags of blood. No previous history
of surgery.
Family History:
Patient had family history of diabetes, cervical and throat cancer and hypertension. Patient denies of familial history of asthma,
stroke, liver diseases, kidney diseases and any psychiatric problems. Patient was previously exposed to pulmonary tuberculosis
because of her both parents. Patient denies of any exposure to any communicable diseases, such as pneumonia. No allergy on foods
and medications.
Personal and Social History:
Patient is seventh among eighth siblings. Her highest educational attainment was Grade 6. She is currently working as
Barangay Health Worker for 26 years. She is married to her husband, 53 years old, for 31 years and had 3 children. Patient is a nonsmoker, non-alcoholic beverage drinker. She prefers to eat fatty foods, drinks 6 to 8 glasses of water per day and drinks 1 cup of coffee
every day. Patient considered doing household chores and taking care of her grandkids as a form of exercise.
Patient lives in a hut, single storey, no bedrooms, one bathroom with pour type latrine, poorly ventilated house. Patients
source of water for everyday and drinking water source is from Maynilad.
OB-GYN History:
OB Score: G3P3 (3003)
G1- 1985, delivered full term, baby boy, unrecalled birth weight, via normal spontaneous delivery, home, hilot, living and healthy, no
fetomaternal complications
G2- 1987, delivered full term, baby boy, unrecalled birthweight, via normal spontaneous delivery, home, hilot, living and healthy, no
fetomaternal complications
G3- 1992, delivered full term, baby girl, unrecalled birthweight, via normal spontaneous delivery, Fabella, OB, living and healthy, no
fetomaternal complications
Patient had her menarche at 16 y/o, lasted for 5 days, consuming 4 pads per day, moderately soaked, not associated with
dysmenorrhea. Subsequent menses were regular with an interval of 27-32 days, lasting for 3-5 days, consuming 3-4 pads per day,
moderately soaked, not associated with dysmenorrhea.
She had her coitarche at 22 y/o. No history of contraceptive use. No history of sexually transmitted infection. No Pap smear
done. Her menopausal age is 52 years old.
Review of Systems
General: (-) weight loss (-) fatigue (-) weight gain
HEENT: (-) migraine (-) vertigo (-) syncope (-) blurring of vision (-) tinnitus (-) sore throat (-) dysphagia (-) lymph node enlargement (-)
goiter (-) epistaxis (-) ear discharge (-) ear pain (-) sore throat (-) throat itchiness
Respiratory: (-) chest pain (-) shortness of breath (-) wheezing (-) dyspnea, (-) cough (-) hemoptysis (-) orthopnea
Cardiovascular: (-) chest pain (-) palpitations (-) tachycardia (-) PND (-) cyanosis
GIT: (-) dysphagia (-) nausea (-) vomiting (-) jaundice (-) hematemesis (-) melena (-) abdominal pain

GUT: (-) dysuria, (-) polyuria (-) urgency (-) frequency (-) hematuria (-) oliguria (-) anuria
Endocrine: (-) weight change (-) heat or cold intolerance (-) polyuria (-) polydipsia (-) polyphagia (-) abnormal growth
Hematologic: (-) easy bruisability (-) easy fatigability (-) pallor
Physical Examination
General Survey:
Vital Signs:

Conscious, coherent, ambulatory, afebrile, not in cardiorespiratory distress

BP: 130/70 mmHg, HR: 72 bpm, RR: 21 cpm, T: 36.8 C
Weight: 65 kg, Height: 154 cm, BMI: 27.41 kg/m2
Skin is warm, with good turgor, no active dermatoses, capillary refill time <2 seconds
Anicteric sclerae, pinkish palpebral conjunctivae, no nasoaural discharge, no tonsilopharyngeal congestion,
tonsils are not enlarged, non-hyperemic, no cervical lymphadenopathy
Symmetrical chest expansion, no retractions, no lagging, vesicular breath sounds, no wheezes, equal vocal
tactile fremitus, no egophony, no bronchophony
Adynamic precordium, Apical beat at 5th ICS left midclavicular line, normal rate, regular rhythm, no murmur
Globular, normoactive bowel sounds, soft, non-tender, no mass noted upon light anstal thd deep palpation
Grossly normal extremities, no edema, no cyanosis, no pallor, with full equal pulses on radial, brachial and
dorsalis pedis, (+) tenderness on hypothenar eminence, left and distal third of left arm, no swelling noted, no
bony deformities, no atrophy

Skin:
HEENT:
Chest & Lungs:
Heart:
Abdomen:
Extremities:
Neuro:

Cerebrum: awake, conscious, coherent

Cerebellum: able to do finger-to-nose test
Cranial Nerves:
I intact sense of smell on both nares
II intact pupillary reflex, pupil size is 2-3mm
III, IV, VI intact extraocular muscles
V intact corneal reflex
VII able to smile, frown
VIII intact gross hearing on both ears
IX, X able to swallow without difficulty
XI able to shrug
XII able to protrude tongue and is at midline
Sensory:
100% on both upper and lower extremities
Motor:
5/5 on both upper and lower extremities
Deep Tendon Reflex:
++ on all reflexes (upper and lower extremities)
Admitting diagnosis:

Musculoskeletal strain (left wrist and forearm)

Plan:

Warm compress/elastic bandage

Naproxen Na 550 mg/tab once a day as needed for pain
Vitamin B complex 300 mg/tab once a day

Salient Features:

53 year old
Female
CC: pain on left wrist & forearm
5 days of pain described as sharp in character, non-radiating, with a severity of 5/10, aggravated by
movement, intermittent and not relieved by rest.
No associated with any other symptoms such as limitation of movement, morning stiffness, erythematous,
swelling and warm to touch
No history of fall or trauma noted
No heterofamilial disease related to rheumatism or any known joint diseases
Non--smoker, non-alcoholic beverage drinke
Prefers to eat fatty foods; drinks 6 to 8 glasses of water per day and drinks 1 cup of coffee every day
Considers doing household chores and taking care of her grandkids as a form of exercise
Vital signs: BP: 130/70 mmHg, HR: 72 bpm, RR: 21 cpm, T: 36.8 C
Weight: 65 kg, Height: 154 cm, BMI: 27.41 kg/m2
PE: Extremities - Grossly normal extremities, no edema, no cyanosis, no pallor, with full equal pulses on
radial, brachial and dorsalis pedis, (+) tenderness on hypothenar eminence, left and distal third of left arm,
no swelling noted, no bony deformities, no atrophy

Differential Diagnoses:

Osteoarthritis
Rule In

Rule Out

53 year old
Overweight (BMI: 27.41)
No forms of exercise
Aggravated with movement

Rheumatoid arthritis

Rule In
-

Rule Out
53 year old
affects the wrist, elbow,
shoulders

cannot be totally rule out

5 days acute in onset

non-symmetric
does not last more than an
hour
ease with activity
associate with diseases
(peripheral neuropathy,
vasculitis, lung involvement,
etc)

Musculoskeletal Disease

Rule In
Description of pain: sharp in
character, non-radiating, with a
severity of 5/10, aggravated by
movement, intermittent and not
relieved by rest
No history of fall or trauma
(+) tenderness on hypothenar
eminence, left and distal third
of left arm, no swelling noted,
no bony deformities, no atrophy

Rule Out
- cannot be totally rule out

Pain is the main symptom of these conditions.

Because the structures affected are located near the joint, moving the joint can be extremely painful and may be difficult.
The pain is more prominent at night.
Some conditions may cause redness, warmth or swelling in the affected area.
Most of these conditions occur suddenly, may last for days, weeks or longer, and then go away. They can, however, occur
again in the same place.

Diagnosis is based on medical history and physical examination.

There are no blood test or Xray abnormalities.
MRI and ultrasound may be useful in the detection of bursitis and tendonitis.
Aspiration of a swollen bursa may be performed to exclude infection or gout.
Blood tests are generally not necessary to diagnose tendonitis or bursitis.
Underlying diseases that may present with symptoms of soft tissue rheumatism like rheumatoid arthritis and diabetes must be
excluded.

Non-steroidal anti-inflammatory medications are needed to reduce inflammation and pain in some patients.
Corticosteroid injections into the affected area are frequently helpful if symptoms persist

Rest
Splints
Heat and cold application
Physical therapy
Occupational therapy
The best treatment is PREVENTION. It is important to avoid or modify the activities that cause the problem. Underlying
conditions such as leg length differences, improper posture or poor technique in sports or work must be corrected.

Arcadio, Katherina Keith M.

JI-In-Charge