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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