Patient Profile:
Name: John Doe
Age: 45 years
Gender: Male
Occupation: Factory worker
Address: 123 Elm Street, Anytown, USA
Medical Record Number: 5678901
Presenting Complaints:
Mr. John Doe presented to the clinic with the following complaints:
Pain in the Right Wrist: He reported severe, localized pain in his right wrist that has been progressively worsening over the past three months.
Swelling and Redness: He noted significant swelling and redness around the wrist joint.
Stiffness and Limited Range of Motion: John experienced stiffness in the wrist and difficulty moving it.
Fever and Fatigue: He mentioned occasional low-grade fevers and generalized fatigue.
History of Presenting Complaints:
The patient reported that the symptoms began insidiously and initially attributed them to overuse and stress related to his job.
Chief Complaints:
Pain in the right wrist.
Swelling and redness in the right wrist.
Limited range of motion in the right wrist.
Generalized fatigue.
Past Medical and Surgical History:
No significant past medical history.
No previous surgical interventions.
Family History:
No known family history of tuberculosis or other joint-related disorders.
Socioeconomic Status:
Mr. Doe is a blue-collar worker with moderate income and access to healthcare services.
Present and Pre-morbid Functional Status:
Prior to the onset of symptoms, Mr. Doe had full functional use of his right wrist.
Currently, he experiences limitations in performing daily activities and job-related tasks due to wrist pain and limited mobility.
General Health Status:
Overall, John’s general health was good before the onset of symptoms, but he has been experiencing a decline due to the wrist condition.
Vitals:
Blood Pressure: 120/80 mmHg
Heart Rate: 80 bpm
Respiratory Rate: 16 breaths/minute
Temperature: 99.0°F (occasional low-grade fever)
Aggravating Factors:
Pain exacerbated by wrist movement and gripping objects.
Stiffness worsens with inactivity.
Easing Factors:
Mild relief with rest and application of ice to the affected wrist.
Examination:
On examination, there is significant swelling and redness around the right wrist.
Limited range of motion with pain and stiffness noted.
Palpation reveals tenderness over the wrist joint.
Mild warmth and erythema present over the wrist.
Sleep and 24-hour Pattern:
John reported difficulty sleeping due to nighttime pain in the wrist.
Nocturnal pain frequently disrupts his sleep.
Duration of Current Symptoms:
Symptoms have been present for three months and have progressively worsened.
Mechanism of Injury/Current Symptoms:
No specific injury was reported.
Symptoms developed insidiously.
Progression Since the Current Episode:
Symptoms have worsened over the past three months.
Pain and stiffness have become increasingly disabling.
Significant Prior History:
No significant prior history of joint disorders or chronic illnesses.
Previous Treatment:
The patient sought over-the-counter pain relief initially, which provided minimal relief.
No previous medical treatment or consultation before this visit.
Diagnostic Test/Imaging:
X-rays of the right wrist revealed joint space narrowing and soft tissue swelling.
MRI showed synovial inflammation and joint effusion.
Differential Diagnosis:
Tuberculous arthritis of the wrist.
Rheumatoid arthritis.
Osteoarthritis.
Septic arthritis.
Gout.
Postural Observation:
The patient tends to keep the right wrist immobilized and exhibits guarding behaviors.
Precaution and Contraindications:
Avoid excessive wrist movement.
Rest the wrist when possible.
Immobilization may be necessary.
Functional Movement Analysis (Sign):
Limited wrist flexion, extension, and radial/ulnar deviation.
Quick Screening Tests/Clearing of Additional Joint Structures:
Negative for signs of septic arthritis.
No joint instability noted.
Range of Motion (ROM):
Limited wrist flexion to 30 degrees.
Limited wrist extension to 15 degrees.
Limited radial/ulnar deviation.
Special Tests:
TB skin test (positive result).
Synovial fluid analysis (elevated white blood cell count and culture positive for Mycobacterium tuberculosis).
Assessment:
Tuberculous arthritis of the right wrist.
Limited wrist mobility.
Generalized fatigue.
Problem List/Complaints:
Tuberculous arthritis of the right wrist.
Pain and limited mobility.
Generalized fatigue.
Treatment:
Anti-tuberculous medication regimen (consultation with an infectious disease specialist).
Pain management (non-steroidal anti-inflammatory drugs, analgesics).
Immobilization with a wrist splint.
Physical therapy for wrist range of motion.
Prognosis:
Favorable with early and appropriate treatment.
Improvement in wrist function and pain relief expected.
Goals:
To control the progression of tuberculosis in the wrist.
To relieve pain and improve wrist function.
To prevent complications and joint destruction.
Interventions:
Administer anti-tuberculous medications.
Prescribe pain management and anti-inflammatory medications.
Provide wrist splint for immobilization.
Refer to physical therapy for range of motion exercises.
Patient Education:
Importance of adhering to the medication regimen.
Proper use of the wrist splint.
Benefits of physical therapy exercises.
Signs of medication side effects.
Patient/Family Education:
Importance of infection control.
Potential for treatment duration.
Supportive care at home.
Monitoring for medication side effects.
Discharge Plan:
Continue anti-tuberculous medications.
Attend physical therapy sessions.
Follow-up appointments with infectious disease specialist and orthopedic surgeon.