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