Welcome TO Clinical Meeting: Presented by DR Shagufa Umma Honey DCH Student Bich

WELCOME
TO
CLINICAL MEETING
Presented by
Dr Shagufa Umma
Honey
DCH student
BICH 1
PARTICULARS OF THE
PATIENT :
Name : Imran
Age : 09 yrs
Sex : Male
Address : Jamalpur
Date of Admission : 04.07.13
Date of Examination : 06.07.13 2
CHIEF COMPLAINTS:
1.Pain and swelling of multiple
joints of both hands and feet
for 2 yrs.
2. On and off fever for same
duration.
3. Unable to walk for 1 week
3
HISTORY OF PRESENT
ILLNESS :
According to the statement of the
informant mother, her son was
reasonably well 2 yrs back. Since
then he developed pain and
swelling of knees, ankles, elbows,
wrists and proximal and distal inter-
phalangeal joints of both the hands
and feet at a time.
4
History of Present illness(Cont..)
Pain was more marked in early morning

with joint stiffness and gradually
decreased during the day which made
him difficult to walk even he stopped go
to school. Pain was associated with low
grade intermittent fever without chills
and rigor.
5
HISTORY OF PRESENT
ILLNESS(CONT..)
With these complaints he visited

qualified doctors and took several
medicine but his mother could not
mentioned the name. As there was no
improvement, he got admitted here for
further evaluation and management.
6
HISTORY OF PRESENT ILLNESS
(CONT..)
There was no history of rash,

photosensitivity, oral ulcer, painful red
eye, sore throat, convulsion, emotional
labiality, chest pain or urinary
complaints.
7
History of past illness:
Nothing significant.
Birth history :
He was delivered normally at term at home
without any perinatal complication.
Feeding history:
He was exclusively breast fed upto 6
months, then complimentary feeding was
started. Now he is on family diet with
adequate calorie and protein.
8
Immunization history:
Immunized as per EPI schedule
Developmental history:
Age appropriate.
Family history:
He is the 2nd child of non
consanguineous parents. His elder
sister & other family members are
healthy .
9
Personal history:
He was a student of Class-III with
normal intelligence.
Socioeconomic history:
He belongs to a lower middle class
family. Monthly income of his father
is around 9,000 Tk.
10
GENERAL EXAMINATION:
Appearance: Ill looking
Pallor : Mild
Jaundice :
Oedema : Absent
Cyanosis :
Clubbing :
11
CONTD
Lymph nodes: Not palpable.
Skin: BCG mark present, no other skin
manifestation.
Throat : No ulcer.
Bed side urine

albumin: Nil
12
Vital signs:
Pulse : 80/min
BP : 85/60 mm of Hg
R/R : 24/min
Temp : 98.4F
Anthropometry:
Weight : 20 kg WAZ: - 2
Height : 120 cm HAZ: - 2
BMI : 13.88 ; falls at 3rd centile.
WHZ : 1
13
EXAMINATION OF LOCOMOTOR
SYSTEM
INSPECTION:
Patient lying on bed with slightly knee
flexed. Boutonniere deformities of both
hands. Spindle shaped proximal
interphalangeal joint deformities of toes
present.
14
PALPATION:
Muscle bulk symmetrically decreased in
lower limbs.
Knee joints: Warm, swollen.
Tenderness:(Grade-2/4)
Fluctuation test and patellar tap : Absent.
Other joints: Tenderness (Grade-1/4).
15
Ankle Could move in all
direction
RANGE OF MOVEMENT: without
difficulty.
Wrist Could move in full range
of movement without
difficulty.
Elbow Could move in full range
of movement without
difficulty.
Small joints of hands and PIP joints of both the
feet hands and feet were
difficult to perform flexion
16
and extention.
NERVOUS SYSTEM EXAMINATION:
Higher psychic function:

Conscious, co-operative, oriented.
Cranial nerves:
Intact.
Bulk of muscle:
Normal in upper limbs, decreased in lower
limbs.
Tone: Normal. Power : 4/5
17
CONTD
Reflexes :
Deep jerks: Normal.
Planter: Bilaterally Flexor.
Clonus ,involuntary movement
Absent.
Gait Limping.
Sensory & cerebellar function

Normal.
Fundoscopic examination: Normal. 18
CARDIOVASCULAR SYSTEM
EXAMINATION:
PULSE:80/MIN
BP:85/60MM OF HG
Precordium:-
Inspection:
No deformity, scar marks.
Palpation:
Apex beat on lf 4th ICS lateral to
midclavicular line.
Percussion:
Auscultation: 19
S1 + S2 + 0
OTHER SYSTEMS REVEALED
NOTHING ABNORMALITY
20
SALIENT FEATURE:
Imran a 9 yrs old boy got admitted in this

hospital with the complaints of pain and
swelling of multiple large and small joints
of upper and lower limbs at a time for 2
yrs. There was early morning joint
stiffness which made him difficult to
walk .
21
Salient feature(cont)
Pain was associated with low grade

intermittent fever. On examination,
Imran was well alert, co-operative, mildly
pale, afebrile, having limping gait. Muscle
bulk symmetrically decreased in lower
limbs.
22
Salient feature(cont)
Both the knee joints were swollen,

hot, tender(grade-2/4)with movement
restriction. There was no
lymphadenopathy, organomegaly, oral
ulcer or history of photosensitivity,
convulsion, emotional labiality, chest
pain, urinary complaints. Other system
revealed nothing abnormality.
23
PROVISIONAL DIAGNOSIS
JUVENILE IDIOPATHIC
ARTHRITIS(POLYARTICULAR)
DIFFERENTIAL DIAGNOSIS:
1. SYSTEMIC ONSET JUVENILE
IDIOPATHIC ARTHRITIS.
2. SYSTEMIC LUPUS ERYTHEMATOSUS
24
INVESTIGATION:
1.Complete blood count:
Total count: 6500/cu mm
Differential count: Neutrophil- 75%
Lymphocyte-23%
Eosinophil-1%
Monocyte-1%
RBC: 4.09 million/ul
Hb : 8.3 g/dl
Platelet : 377000/cu mm
MCV: 65fl MCHC: 31 g/dl 25
MCH: 20pg RDW : 18 %
Investigation(cont.)
2.Peripheral blood film:
RBC- anisochromic with anisocytic
WBC- neutrophilia
Platelet- normal
3. ESR-90 mm in 1st hour
4.CRP: 60.3 mg/l
5. RA test: <8 IU/ml (negative)
26
5. Urine R/E :
RBC- nil
Pus cell: 0-2/ HPF
Epi. Cell: 1-2/ HPF
Albumin: nil
Cast: nil
6.Opthalmological exam:
Slit lamp exam: Normal
27
Investigation(cont.)
7. X-RAY OF KNEE JOINT & WRIST

JOINT
28
Investigation(cont
.)
8. Serum electrolytes :
Na 142.6mmol/l
K 4.3mmol/l
Cl 103.2mmol/l
10. Blood urea: 1.8 mmol/l
11. Serum creatinine: 42.1umol/l

29
12. SGPT (ALT) : 32 unit/l

FINAL DIAGNOSIS:
Sero- negative Polyarticular

Juvenile Idiopathic Arthritis.
30
TREATMENT:
COUNSELING
+MULTIDISCLIPNARY
APPROACH
o Diet: protien, calorie, calcium,Vit D
riched.
o Tab. Naproxen (250mg)
1/2 +0+ 1/2 (after meal)
o Syp. Ranitidine
1 tsf+0+ 1 tsf (before meal)
31
o Physiotherapy .
Tab. Prednisolone (20mg)
1 +0+0 (after meal).2wks, then
1+0+0. 2wks,every alternate day
then
1/2+0=04wk
Tab. MTX (2.5 mg)
3 tab weekly
Tab. Folison (5mg)
0+1+0
F/UP after 2months.
32
THANK YOU
33

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WELCOME

Pain was more marked in early morning

With these complaints he visited

There was no history of rash,

Bed side urine

Higher psychic function:

Sensory & cerebellar function

Imran a 9 yrs old boy got admitted in this

Pain was associated with low grade

Both the knee joints were swollen,

7. X-RAY OF KNEE JOINT & WRIST

10. Blood urea: 1.8 mmol/l

11. Serum creatinine: 42.1umol/l

12. SGPT (ALT) : 32 unit/l

Sero- negative Polyarticular

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