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38 year old female with diffuse headache and multiple joint pains

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

A 38 year old female sales person by occupation came with complaints of 
Diffuse headache since 1 year 
Multiple joint pains since 1 year
Lumbar-cervical-shoulder joint-knee joint-wrist-PIP
DIP -spared
 

HOPI
Patient was apparently asymptomatic 1 year back then developed headache -diffuse type,insidious in onset ,gradually progressive 
Relieved on medication

Multiple joint painsnot associated with early morning stiffness and fever.joint pains increases with work associated with neck pain
Tingling of both upper limbs 
Past history 
K/C/O HTN -not on medication 
N/K/C/O DM,BA,EPILEPSY, TB

GENERAL EXAMINATION -
Patient is Conscious, coherent,co operative well oriented to time,place,person

pallor-+
No icterus, No Cyanosis, No lymphadenopathy, No edema

VITALS-
Temperature -98.6F
Pulse rate- 84bpm
Blood pressure-120/90mm hg
Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

CARDIOVASCULAR SYSTEM:
S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:
BAE present,NVBS

CENTRAL NERVOUS SYSTEM:
NAD

PER ABDOMEN:Soft, non tender
No guarding, No rigidity 
Bowel sounds present 
INVESTIGATIONS-
USG abdomen - grade 1 fatty liver
ESR-
27/4/22-60 mm/1st hour
4/5/22-50mm/1st hour
RA factor -negative
CRP-negative
ANA-negative
CBP-
Hb-13.1gm/dl,TLC-8000cells/cumm,plt-2.56lakhs/cumm
TB-0.65mg/dl
DB-0.24mg/dl



DIAGNOSIS-
?RHEUMATOID ARTHRITIS 

Treatment-
1.Tab AMITRIPTYLINE 10mg 1/2 tab /PO/HS




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