Skip to main content

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




Comments

Post a Comment

Popular posts from this blog

Medicine case

CASE HSITORY AND CLINICAL FINDINGS 29 year old female patient came to the casualty with h/o consumption of rodentiscide paste / ratatol poisoning 6days back [ 10 gm - approx. containing 3% yellow phosphorus ] followed by complaits of 1 episode of fever with chills 4 days ago subscided with medication . complaints of vomiting since 4 days  2to 3 episodes per day ,food as contents complaints of  yellowish discolouration of eyes and body since yesterday associated with discolouration of urine and dcrease appetite since 2 days . patient visited to local RMP yesterday morning she under went investigations : her Hb 3.7 gmd /dl ,TB : 5.6 DB 3.2 AST 270 ,ALT 340 ,ALP 135 ,TP 6.4 ,albumin 3.9 globulin 2.5 complaints of burnung sensation in chest ,giddiness today morning associated with palpitations  so she was brought to our hospital, no history of loose stools, pain abdomen, bleeding gumsno discouluration of stools ,no h/o sob ,blood in stools ,h/o fever 7 years ago, she got test...
Post a Comment
Read more

medicine case

 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 79yr male presented to casuality with chief complaints of  pedal edema  since 10 days , shortness of breath since 5 days   Patient was apparently asymptomatic 10days back then came with c/o   Pedal edema since 10 days -pitting type ,shortness of breath since 10 days insidious in onset , grade 3(marked limitation in activity) ,Fever 7  days back which subsided ,Dry cough 7 days back which subsided. PAST HISTORY - K/c/o hTN since 10 yrs on  regular medication-telmisartan 40mg H/o CVA 10 yrs back for which he was treated.  Not a k/c/o diabetes , TB,asthama,cvd , ep...
Post a Comment
Read more

A 50 year old with sob,pedal edema

"This is an 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 patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment" A 50 year old female patient came to casuality with complaints of pedal edema since 3 months ,decreased urine output since 3 months ,shortness of breath since 3 days HOPI Patient was apparently asymptomatic 3 months back then developed fever -low grade not associated with chills Pedal edema 3 months ago Decreased urine output 3 months ago Sob -progressed to grade 4i Patient  was advised for hemodialysis but pt attendees were not willing Patient has been taking nsaids since past...
Post a Comment
Read more