A 55 year old female with Rheumatoid arthritis
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Chief complaints:-
A 55years old female came to causality with cheif complaints of
C/o neck pain since 4years
C/o headache since 4 years
C/o B/L wrist joint and ankle joint pain since 4 years
C/o generalized weakness & difficulty in lifting weights since 4years
History of Present illness:-
Patient was apparently asymptomatic 4yr ago then developed fever which is insidious in onset not associated with chills and rigours
No H/o cough ,cold at the time of fever.
Patient developed headache which is o diffuse in nature not associated with nausea vomitings since 4 years
No H/o giddiness
C/o B/L wrist joint - Lf>Rt
Wrist,1st mcp of both hands
No deformity
No swelling
B/L ankle joint pains -tenderness (+) since 4years
C/o neck pain radiating to shoulders since 4years
C/o tingling sensation of both feet and soles since 4years
Early morning stiffness(+)
No c/o pain abdomen loose stools burning micturiation decreased urinary out put
History past illness:-
Shortness of breath ,chest pain , palpitations ,sweating ,constipation (+)
C/o low volume stools
H/o hysterectomy done 20yr back
H/o chikungunya infection 4yr back
N/k/c/oDM, HTN,TB,Asthama ,Epilepsy,CVD,CAD,thyroid disease
Personal History :
Married
Occupation -Farmer
Appetite-normal
Mixed diet
Bowel- Regular
Micturition-normal
Habit/addiction
Alcohol-drinks toddy stopped since 4year back
Occasionall alcoholic
Smoking from 12 years stopped 4years back
Family History:
Not significant
Menstrual History:
Age of menarche- 13 years
Menstrual cycle- 15/30 regular
Present - hysterectomy 20years back
Obstetric history:
Age of marriage- 18years
Age of First child -19years
No of living children-4
Physical History:-
Pallor-absent
Icterus- absent Clubbing-absent
Cynosis- absent Oedema -absent
Lymphadenopathy-absent
No Malnutrition
No Dehydration
Vitals:- Temp- 98F
Pulse rate -84/min
Respiratory rate-16/min
BP-110/80mmHg
Spo2- 98%
GRBS- 134mg%
Systemic Examination:
CVS - Cardic sound S1&S2 heard
Cardic mummers- No
Respiratory system :-No Dyspnoea
No Wheeze
Position of trachea -central
Breath sounds- vesicular (normal)
B/L air entry -Normal
Abdomen :- Shape of abdomen - scaphoid
Tenderness-No
Palpable masses-No organomegaly
Hernial orifices- Normal
Liver- Not palpable
Spleen- not palpable
Bowel sounds - No
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
Reflexes:- Right. Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knees ++ ++
Ankles ++ ++
Cerebral signs:-
Finger -Nose in-coordination — No
Knee-heel in coordination —No
Provisional Diagnosis:-
Rheumatoid arthritis
Investigation :-
Haemogram,serology,left,Rft,FBS,PLBS,CRP,RA factor, x-ray spine wrist,2ECHO,
USG-abdomen,x-cervical spine
Treatment:-
T.Naproxen
T.pantop
Syrup cremothin plus
Follow up
55/F
S-
O- pt is c/c/c
BP- 120/80
PR-84bpm
RR-18cpm
CVS-S1,S2 heard
CNS-NAD
P/A-soft non tender
RS-NVBS
A-seropositive
Rheumatoid Arthritis
P- T.pantop 40mg
Syrup cremothin plus