State Medical and Pharmaceutical University,, Nicolae Testemitanu, USMF

History and Examination of Rheumatological case

Professor: Eugen Russu

From: Baher Krayem Gr. 1540

Chisinau 2011

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. 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. Additional symptoms: Morning stiffness that lasts 20-30 minutes every day. Birthday: 2/11/1969 Main Complaint: Pain in knees. Cold sweats. Headache also is associated with the pain. R (Radiation) = The pain is located in the sacral region. . It wakes the patient during the night. nausea. P (Palliative/Provocative) = Ibubrefen releifs the pain. When the weather is cold the pain usually is increased. (to exclude GIT infection). but in this time the pain lasted more than two weeks. Meloxicam also.Case History Patient Name: Odainic Aliona Age: 42. and radiates downwards to the ankle. The pain generally for one week every 2-3 months. Q (Quality) = The pain is described as deep aching pain. The patient says that NO diarrhea. or vomiting is present. tibia and sacral region that started two weeks before hospitalization. and in the knees. the pain is episodic and not constant and lasts about half an hour.

She doesn’t have Tuberculosis. She does physical activity (Aerobics) 2 times a week. At the year 2009 she had tonsillectomy. she is married with 2 kids. Stress is present at work and at home and usually it increases the pain. due to the detection of Chlamydia infection. She drinks coffee a lot. She had natural abortion before. She has allergy to Cephalosporin’s. She drinks only occasionally. She suffers from hypotension (that’s what she claims). Social History: She works at a pharmacy. Diabetes. No history of trauma. The aerobics doesn’t affect the pain. She declines any Rheumatoid Arthritis during childhood. She had also Hepatitis B (after dental treatment).Patient History: The patient started to suffer from pain since the year 2002. Her mother suffered from RA. but she was treated and fully recovered (according to her version). She says that she doesn’t and didn’t had any STD in the past. or any cardiovascular disease. Habits and Allergy: Non smoker. .

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 .

Redness is present in the mentioned joints. No deformity. and sacral region. wrist. sacral region and the tibia.120/70 R Arm/Auscultation. and left ankle. Pain is present in the right knee. Local edema is present in the left wrist. No atrophy is present. 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. left knee more than the right knee.126/70 Heart Rate by radial pulse palpation: 80 beats/minute .5° C oral Blood Pressure: R Arm/cuff (Systolic). Swelling is present at the right knee. Tenderness is present at the knee. sacral region and ankle. Normal muscle tone. There is slight limitation in motion and activity.122/70 L Arm/Auscultation. palpation.Physical examination: Musculoskeletal: Inspection.126/70 L Arm/cuff (Systolic). movement and tone levels were examined in the various joints and muscular system in the body. Heat is present also.

translucent.Respiration Rate: 14 breaths/minute HEENT Head: Configuration.pink .normal texture Scalp. with normal light reflex Nose: Color. tenderness Auditory Canal. mobile Thyroid: non-palpable or palpable.white Conjunctiva. No discharge Throat and Mouth: Teeth: Present and in good dentition Tongue: No lesions Gums and Mucosa: No swelling. bleeding. No lesions Suprasternal Notch: No pulsation HEART . lateral rotation and tilting Trachea: midline. masses.TM’s gray. normal size & consistency.lesions.normocephalic Hair. extension.pink Ears: External Ear. infection Pharynx and Tonsillar Fossa: normal NECK Active ROM: nornal flexion.normal Eardrum.No lesions. tenderness Eyes: Sclera.

No parasternal impulses.PMI not visible Palpation.heard best at base.no JVD at 45° Carotid Arteries: Palpation (Amplitude and Contour).No murmurs THORAX & BACK Observation: symmetrical expansion with respiration Percussion: No spinal tenderness. A2 > P2 Extra Sounds. nromal vesicular breath sounds ABDOMEN Observation: scaphoid No scars. No CVA (costovertebral angle) tenderness LUNGS Percussion and Palpation of Lung Fields.normal upstroke & amplitude bilaterally Auscultation: No bruits Precordium: Inspection.clear. normal intensity S2. nl splitting. No bruits . S4 Murmurs.heard best at apex.palpable in 5th ICS Auscultation: S1. striae Auscultation: normal bowel sounds.Neck Veins. No thrills PMI.normal resonant percussion Auscultation.No S3.No lifts or heaves .

not palpable Pre and Post Auricular.Size.not palpable Submandibular.not palpable Pectoral.not palpable Epitrochlear: not palpable Superficial Inguinal (horizontal and vertical): not palpable .not palpable Subscapular.not palpable Suboccipital. guarding Deep.not palpable Lateral Axillary. masses Liver: Palpation.not palpable Axillary: Central Axillary.non palpable SKIN: normal.non palpable Kidneys: Left.No tenderness.non palpable Right. masses.liver edge not palpable Percussion .~10 cm in R midclavicular line Spleen: Palpation.not palpable Supraclavicular.not palpable Anterior and Posterior Cervical.Palpation: Superficial. No lesions LYMPH NODES Neck: Submental.No tenderness.

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

Biochemical test: Urea = 3.4 Na = 142 .9 Cholesterol = 5.9 Triglycerids = 0.6 Creatinine = 0.69 K = 4.4 RBC = 4.2 WBC= 5.7 Bilirubin = 16 Glucose = 3. Hb = 12.9 ESR = 11 Complete blood count is normal.Laboratory Tests: The patient is sero-negative for Rheumatic factor.

Diagnosis: Sero-negative Spondyloarthritis Reactive Arthritis. diarrheal illness or STD (according to her story). Asymmetric Sacroilitis X-ray stage II. There is involvement of inflammatory process.500 mg . the joints that are affected are large.6 days (Macrolide) Roxithromycin . after THEN 250 mg / day . Functional disability 0-1. weight bearing joints (knees and joints) with spinal affection.1 g / day (Macrolide) Azithromycin .first day. Treatment: We should administer antibiotics: Doxycycline . 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. Although she excludes any urinary.200 mg / day (Tetracycline) Or Clarithromycin . like: Diclofenac (75-150 mg) or . Oligoarthritis. asymmetric oligoarticular joint involvement.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.

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.Meloxicam (7. Sulfasalazine (2-3 gr per day) is widely used in all seronegative spondylitis.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.5-1 mg/kg/d can be used initially and tapered according to response. DMARDs have also been used in reactive arthritis. In addition Sulfasalazine may be beneficial in some patients. Prednisone 0. . although their disease-modifying effects in the reactive arthritis setting are uncertain.

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