This paper solves the following cases scenarios: Case A: Mrs Patrick is a 52 year old female, complaining of aching pain in her knees. She also complains of stiffness in her knee joints, esp. on waking up in the morning since past 1 month. She has noticed the stiffness increases after sitting for longer periods without moving her legs. Both the knees are swollen and painful. She mentioned that last winter, she had developed a sudden swelling and redness in her fingers. The joints were painful and she could not do any household work like washing or cleaning dishes then, as it increased the pain. She was given some painkillers to help with the pain. After this, the pain and swelling would come and go at irregular intervals through out the year. She also mentioned that after the first episode, her fingers have always been a little bit stiff. Upon interrogating about her family history she said her mother died of disability due to rheumatoid arthritis. Her elder brother suffers from gout. Her father is still very healthy and energetic at the age of 95 years. Physical appearance: She is extremely overweight, short stature. She weighs 95kgs and is about 151cms tall. She walks with the help of a walking stick and has difficulty when climbing stairs. Physical examination: Both knee joints are swollen and there is restricted movement. The range of movement is restricted. Her fingers have painless stiff nodosities in the interphalangeal joints. Crepitus can be felt in the left knee upon examination. Vital signs: Test Result Normal range Blood pressure 130/90 mm of Hg (110/70 – 130/90) mm of Hg Pulse rate 80, per minute 60-100 per minute Respiratory rate 14 per minute 12-16 per minute Temperature 36.9 ?C 36.6 – 37.2 ?C Case : Mrs. Thomas is 35 years old physical trainer at "Health First Fitness center" since past 5 years. Recently she has been complaining of pain and numbness in her hand and fingers. She describes it as "pins and needles" with burning and tingling sensations. Mrs Thomas is a mother of two young girls and is pregnant with her third child. She mentioned that she suffered from similar pains during her first pregnancy, but the pain was alright after that. She is three months' pregnant and is on insulin for Gestational diabetes. Her hands are slightly puffy in the morning. She gives a past history of falling from a swing at the age of 13 and she had to wear a collar for about 2 weeks. No neurological damage occurred because of the fall and she has had no neck or arm pain since then. On examination: Hands: slightly puffy Joints: normal Range of Movement. Thenar eminence is wasted bilaterally Sensory examination: touch sensation in the thumb, index and middle finger of both hands is altered. Sustained wrist flexion, for about 1 minute reproduces her symptoms of numbness of the hands
¶ … differential diagnosis for Mrs. Patrick and give the most likely probable diagnosis.
A review of the case reveals that Mrs. Patrick could be suffering from Fibroblastic rheumatism, Rheumatoid Arthritis, Sarcoid arthropathy, Acute viral polyarthritis or Rheumatoid Arthritis.
Fibroblastic rheumatism is noted by Chkirate and Job-Deslandre (2001) to be a very rare disease of an unknown etiology. It however shares certain features of arthritis, nodules as well as arthraglia. The disease causes flexion contractures in most of the patients, a symptom which Mrs. Patrick lacks. In half the cases, thickened palmar fascia is presented.
Sarcoid artropathy
This is a chronic arthritis in the sarcoidosis and it may be polyarticular or oligoarticular. In most cases, it presents itself similarly to RA.In most cases it affects knees, hands, ankles and wrists as well as interphalangeal joints and metacarpophalangeal. It is also normally associated with parenchymal pulmonary disease.It is distinguished from Rheumatoid Arthritis by:
The elevated concentration of angiotensin converting enzyme (ACE) in the serum
Chest radiography may show elements of sarcoidosis.
Acute arthritis pattern together with Lofgren's syndrome in the patients is never observed in RA cases.
Acute viral polyarthritis
This may be caused by a wide rage of viruses such a rubella (Smith, Petty, Tingle, 1989) HBV and parvovirus B19 (Smith, Woolf, Lenci,1987).Serologic testing can be used in the identification of the viruses in patients.
Conclusion
The patients has Rheumatoid Arthritis due to the fact that she presented its most common symptoms as well as a genetic link (Vossennar,2004) (mother had it).
2. Give an explanation of the pathological process involved to produce the signs and symptoms of Mrs. Patrick
According to Vitali et al. (1999) the pathological process in RA starts with the presentation of a relatively unknown antigen for 'rheumatoid' by an antigen presenting cell to the CD4 +T cell receptors. The second step is the activation of CD4 +T cell and then of the cytokine network. This then leads to the development of the signs and symptoms.
3. Mrs. Patrick is concerned that her condition may have some serious complications to her health. Explain how the family history and personal history of the patient is relevant to her present condition and what complications may develop from this condition?
Rheumatoid Arthritis is noted to have a genetic link (Vossennar,2004). The genetic link could be the one that has caused the disease to be present in Mrs. Patrick since his mother also had the disease.The patients personal history is also important since the disease could be caused by certain injuries and health conditions.The complication which may arise from her condition include atherosclerosis, myocardial infarction (heart attack),stroke, endocarditic,, pericarditis and Pulmonary heart disease.
4. Suggest the further investigation tests to confirm your diagnosis and explain what findings to you expect from these tests.
Antinuclear antibody (ANA) testing
A negative antinuclear antibody (ANA) testing effectively excludes systemic lupus erythematosus (SLE) as well other forms of systemic rheumatic diseases. The Antinuclear antibody (ANA) tests may be positive for 75% of the RA patients. In those with positive negative antinuclear antibody (ANA) test, anti-Smith antibody and anti-double stranded DNA testing must be performed.
Complete blood count (CBC)
Complete blood count (CBC) with both platelet and differential count, kidney function, test of liver, urinalysis as well as serum acid. The complete blood count (CBC) is usually abnormal in patients with RA. Thrombocytosis and anemia consists of very chronic inflammation.
Radiography
Radiographs of the feet, hands and wrists can be used at the time of the initial evaluation as a baseline used form monitoring for the progression of disease. Join erosion characteristics may be observed in RA patients.
5. Discuss the management option for this patient
The management options include the use of medication (Pharmacothherapy) (disease-modifying antirheumatic drugs ) (Rindfleisch and Muller,2005). The pharmacotherapy alternative involves the use of nonsteroidal anti-inflammatory drugs (NSAID) necessary for the control of pain as well as a selective application of low-dose oral as well as intra0articular gkucocorticoids.
Nonpharmacologic treatments
There are a number of nonpharmacologic treatments that can be used in the management of rheumatoid arthritis. Some of these include therapeutic fasting, spa therapies, dietary supplementation of the very essential fatty acids, exercise as well as journaling. Short-term benefits can be achieved by the application of the multi-disciplinary approach as well as patient education. Others suggest herbal medication can be used by attest of its efficacy is conspicuously missing.
Case study B
Case 2
1. Discuss the possible causes for Mrs. Thomas's presenting problem and give the most likely probable diagnosis for her.
Mrs, Thomas could be suffering from either Multiple Sclerosis or carpal tunnel syndrome. What makes it to be likely to be suffering from carpal tunnel syndrome the fact that its genesis is pegged on her pregnancy and not any form of injury due to work or from falling. However a review of the symptoms and the application of the diagnostic criteria reveals that she has carpal tunnel syndrome
2. Give an explanation of the pathological process involved to produce the signs and symptoms of Mrs. Thomas.
According to Gorsche (2001) CTS is a complex symptom that results from the compression of a person's median nerve at the carpal tunnel. The median nerve entrapment is noted as the pathological process which causes the symptoms associated with CTS.
3. Suggest the further investigation tests to confirm your diagnosis and explain what findings to you expect from these tests.
The tests for CTS are Tinel and Phalen tests.
Tinel test
Tinel test is a special test that involves the wrapping of the writs with a small surgical hammer and the application of pressure to the patient's median nerve that lies in their writs. Carpal tunnel syndrome e is positively confirmed if the patience feels/experiences a rather tingling sensation in their fingers or if they experience shock.
The Phalen test
The Phalen test involves the testing of the amount of wrist flexion of a given patient. The patient is told to have their forearms in an upright position with their fingers placed in a downward position while the back of their hands are gently placed together.
If the presence of the carpal tunnel syndrome is positively confirmed then the physician should recommend some form of treatment which should be initiated as soon as possible before further damage is done. The treatment for the syndrome ranges from simple physical therapy to painkilling drugs. Should the case be a severe one then the patient may have to undergo release surgery in order to help them relieve pressure that has built up around the media nerve.
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