1801006016-short case

 

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CASE:

A 49 year old female came with chief complaints of pain in the joints since 10 years.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 years back.She then developed fever (on and off type) for which she takes paracetamol (2-3 everyday).She had 2-3 episodes of vomiting,headache and increased frequency of micturation(15-20 times a day).

She then developed pain and swelling in her wrist,ankle,shoulder,elbow,hip,metacarpal phalanges,metatarsal joints and lower back which is radiating to both her legs till feet for which she was taken to the hospital.The medication prescribed to her provided her temporary relief.

She also complaints of pedal edema and stiffness in the joints as soon as she wakes up in the morning.

She has stopped her medication one month back.

DAILY ROUTINE:

She wakes up at 6:00 am in the morning.She takes a head shower everyday as she believes that it reduces her headache.She does the household chores,gets groceries and cooks food.She works at her farm from afternoon to evening and occasionally sells the produce in the market.Later in the night she cooks dinner and sleeps by 8:00pm.

PAST HISTORY:

Not a known case of Diabetes mellitus,Hypertension,Asthma,epilepsy

PERSONAL HISTORY:

Diet: used to have a mixed diet but now she stopped consuming meat

Apetite: decreased apetite

Sleep: reduced

Increased frequency of micturation(15-20 times a day)

Addictions: none

GENERAL PHYSICAL EXAMINATION:

Pallor:present

Icterus:absent

Cyanosis:absent

Clubbing:absent

Lymphadenopathy:absent

Edema: no pedal edema present at the time of examination 

VITALS:

Temperature:100.9 degree fahrenheit at the time of examination

Pulse:70 bpm

Respiratory rate: 24cpm

BP: 110/70 mm hg

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard and no murmurs are heard.

RS: Bilateral vesicular breath sounds are normal

CNS: no focal neurological deficits

Abdomen: soft and non tender

EXAMINATION OF THE JOINTS:

Wrist joint:  partial movement of flexion and extension 

Shoulder joint: she can lift her shoulders but not straight above her head at shoulder joint

Elbow: she can flex and extend normally

Knee and ankle joint: unable to flex completely

 

INVESTIGATIONS:

  

FBS: 83mg/dl

Serum creatinine: 1

Sodium: 137 mEq/l

Potassium: 3.6 mmol/l

Chloride:106 mEq/l

ESR:120

Hb:7.5

TLC:4000

PCV:23

RBC:3.59

Peripheral smear: mild anisopoikilocytosis with hypochromic microcytic pencil forms and few tear drop cells and normocytes are seen.

ECG:

On 07/07/2022, Patient had complained of pain and tenderness in both the breast.

 DIAGNOSIS:

Rheumatoid arthritis with Chronic anemia

TREATMENT:

Tab prednisolone 100mg OD

Tab Methotrexate 7.5mg weekly

Tab folic acid 5mg

Tab naproxen 250mg TID

Tab amitryptalin 10mg 

DISCHARGE SUMMARY: