RHEMATOID ARTHRITIS

A 45yr old female came to causality with chief complaints of neck pain , headache and wrist and ankle joint pain since 4 yrs 

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was apparently asymptomatic 4 yrs ago the she developed fever insidious in onset, not associated with chills and rigor. 

𒊹︎︎︎ She developed headache diffuse in nature , not associated with nausea and vomitings since 4 yrs

No H/o cough, cold at the time of fever

𒊹︎︎︎ No H/o giddiness
𒊹︎︎︎ C/o B/L wrist joint paina and ankle joint pains
𒊹︎︎︎ C/o Metacarpo phalanges pain (+)
𒊹︎︎︎ C/o Interphalanges pain (+)
𒊹︎︎︎ C/o Tenderness present over wrist,mcp, Ip
𒊹︎︎︎ H/o fever & episode in last 8months
𒊹︎︎︎ Last episode 20days back
𒊹︎︎︎ Fever last for 1day relieved after taking medication
𒊹︎︎︎ H/o oral ulcer on hard palate since 10days 

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐀𝐒𝐓 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

𒊹︎︎︎ H/o CVA left Up & Ll weakness &slured speech 10 years back
𒊹︎︎︎ H/o Appendectomy 8year back 
𒊹︎︎︎ N/k/c/o DM, HTN,TB,Epilepsy,CAD, 
𒊹︎︎︎ Used Ayurvedic medication 2 months back for 15days

𝐏𝐄𝐑𝐒𝐎𝐍𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

𒊹︎︎︎ Married
𒊹︎︎︎ Occupation -driver
𒊹︎︎︎ Appetite-decrease 
𒊹︎︎︎ Mixed diet 
𒊹︎︎︎ Bowel- Regular 
𒊹︎︎︎ Micturition-normal
𒊹︎︎︎ Habit/addiction 
𒊹︎︎︎ Alcohol-toddy dinner since 20yr 
𒊹︎︎︎ Occasionall alcoholic
𒊹︎︎︎ BD since 25year (15 per day)

𝐅𝐀𝐌𝐈𝐋𝐘 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

𒊹︎︎︎ No similar complaints in the family. 

𝐏𝐇𝐘𝐒𝐈𝐂𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

(1) GENERAL HISTORY :-

Height- Weight-

Pallor-absent 
Icterus- absent Clubbing-absent
Cynosis- absent Oedema -absent 
Lymphadenopathy-absent 
No Malnutrition 
No Dehydration 

𒊹︎︎︎ Vitals:- Temp-Afebrile
Pulse rate -82/min
Respiratory rate-20/min
BP -100/70mmHg

𝐒𝐘𝐒𝐓𝐄𝐌𝐈𝐂 𝐄𝐗𝐀𝐌𝐈𝐍𝐀𝐓𝐈𝐎𝐍 :-

𒊹︎︎︎ CVS - Cardic sound S1&S2 heard
Cardic mummers- No

𒊹︎︎︎ Respiratory system :-No Dyspnoea
No Wheeze
Position of trachea -central
Breath sounds -vesicular(normal)
B/L air entry -Normal 

𒊹︎︎︎ Abdomen :- Shape of abdomen - scaphoid 
Tenderness-No
Palpable masses- No organomegaly 
Liver- Not palpable 
Spleen- not palpable 
Bowel sounds - yes 
Hernial orifices- Normal

𒊹︎︎︎ CNS - level of consciousness -conscious 
Speech- Normal
No Signs of meningical irritation ( neck stiffness, kernigs signs)
Cranial nerves-normal
Motor system- normal
Sensory system-normal 
Glasgrow scale

𝐈𝐍𝐕𝐄𝐒𝐓𝐈𝐆𝐀𝐓𝐈𝐎𝐍𝐒 :-
𒊹︎︎︎ USG :-
-small shrunken Right kidney with grade-3 RPD changes 
- Grade-2 fatty liver with mild hepatomegaly
- Right renal cortical cyst 

𒊹︎︎︎ 2D ECHO :-
- Good LV systolic function 

𒊹︎︎︎ HAEMOGRAM -

𝐏𝐑𝐎𝐕𝐈𝐒𝐈𝐎𝐍𝐀𝐋 𝐃𝐈𝐀𝐆𝐍𝐎𝐒𝐈𝐒 :-

𝙎𝙔𝙎𝙏𝙀𝙈𝙄𝘾 𝙇𝙐𝙋𝙐𝙎 𝙀𝙍𝙔𝙏𝙃𝙀𝙈𝘼𝙏𝙊𝙐𝙎 

𝐓𝐑𝐄𝐀𝐓𝐄𝐌𝐄𝐍𝐓 :- 

- MUCOPAIN GEL- thrice daily
- T. PCM-650 - thrice daily
- T.BENFOMET PLUS- once daily
- T.PREGABALIN- once daily
- T.BACLOFENX-L- once daily
- T.LORAZEPAM - once daily
- T.NICOTINE GUMS- twice daily
- T. HCQ-200mg/BD

𝐀𝐃𝐕𝐈𝐂𝐄 :- 
No active intervention Needed from nephrology

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. Patient and his/her attenders have been informed and their consent has been taken. A 65 yr old female was brought to the casualty with  complaints of  • Difficulty in moving upper limbs and lower limbs since 3
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