45 year old female with rheumatoid arthritis with RA Factor positive
8/04/2023
This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.
Name: Manvitha (intern)
45 years old female came with
C/O neck pain since 4 years
C/O headache since 4 years
C/O B/L wrist joints since 4 years left side more than right
1st metacarpophalengeal of both
C/O B/L ankle joint pain since 4 years
C/O generalised weakness and difficulty in lifting weights since 4 years
HOPI:
Patient was apparently assymptomatic 4 years back and then patient developed
C/O neck pain radiating to both shoulders since 4 years
Patient developed headache diffuse in nature not associated with nausea and vomiting since 4 years
C/O
Joint pains such as wrist and ankle joint pains which is insidious in onset gradually progressive associated with early morning stiffness lasts for 2 hours
aggravated relatively at end of the day difficulty in doing daily activities lasting for 2 hours , associated with fever- insidious in onset low grade not associated with chills and rigore on and off since 4 years
Patient also complaints of small joint pains such as metacarpo phalyngeal joints and proximal inter phalyngeal joint
C/O tingling sensation of both the feet and soles since 2 years
C/O lower back ache on and off since 4 years
C/O low volume stools since 4 years
No C/O pain abdomen, loose stools, burning micturition decreased urine output, SOB, chest pain, palpitation, sweating
Past history
N/K/C/O DM, HTN, TB, Asthma, epilepsy, CVA,CAD, thyroid disorders
H/O hysterectomy done 20 years back
H/O chikungunia infection 4 years back
Personal H/O
Diet: mixed
Appetite : normal
Bowel: constipation on and off
Bladder: regular
Sleep: adequate
Habit : occasionally drinks toddy stopped 4 years back
Family H/O not significant
Menstural H/O
AOM: 13 years
15:30 regular cycles in past
Hysterectomy done 20 years back
General examination
Patient is Conscious, coherent, cooperative, moderate built and moderately nourished
No pallor, icterus, cyanosis, clubbing, lymphadenopathy,
VITALS
temp: 98.6F
PR: 84bpm
RR:16cpm
BP:110/80mmhg
SpO2: 98 @ RA
GRBS: 134mg/dl
Systemic examination
CVS:S1S2 hears, no murmurs
RS:BAE+ , NVBS +
P/A: soft, no. Tender
CNS: NAD
Investigations
Wrist X ray Ap view
Provisional diagnosis
SEROPOSITIVE RHEMATOID ARTHRITIS
Treatement given
Tab naproxen PO/BD
Tab pan top 40mg PO/OD/BBF
SYP cremaffin plus 10ml PO H/S
Tab wysolone 10mg PO/OD
TAB methotrexate 7.5mg PO once a week
TAB folic acid PO/OD
TAB Neurokind LC PO/OD
TAB aceclo p PO/SOS
Comments
Post a Comment