23/F P3L3 with multiple joint swellings
LThis 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
26 Year old, P3L3, last child birth 5 years back, a homemaker came to OPD with chief complaints of multiple joint pains, and backache since 3 years
Pt was apparently asymptomatic 3 years back, then developed multiple joint pains, involving small and large joints (B/L DIP, PIP, MCP, wrist, elbow, knee, shoulder, ankle)
Low backache since 3 years
A/w ROM, swelling, low grade fever
Morning stiffness (+) for 10-15 min before resuming activity
20/2/21
RA- positive (February 2021)
Used :
T. METHOTREXATE 7.5MG PO/once weekly
T. SULFAZALAZINE 500MG PO/OD
T. OLFENAC-SR 200MG po/od
T. METHYLPREDNISOLONE (?dosage)
? DICLOFENAC GEL
Used for 6 months with mild reduction in severity of symptoms, discontinued hereafter
Pt is c/c/c
Mild pallor
No icterus, cyanosis, clubbing, lymphedema
CVS- S1, S2 heard
RS- BAE (+)
P/A- soft, non tender
CNS- NFND
Local examination-
MCP, DCP Swelling (+)
No raise of temprature
ROM (+)
No tenderness
Wrist :
ROM (+)
Tenderness (+)
Swelling (+)
L/E (Musculoskeletal system)
Involvement of multiple joints (both large and small)
?Asymmetry (+)
Restriction of movement at Right shoulder
Pain at ankle joint (L>R)
Morning stiffness (+)
No other systemic involvement
Advised: xray B/L wrist with hand, LFT, RFT, Hemogram
Provisional Diagnosis- RHEUMATOID ARTHRITIS WITH MCHC ANEMIA
Diagnosed as early stage of Gingivitis
Scaling done (one session),advised another session, practise oral hygiene, brushing twice a day and prescribed mouth wash and gum paint for inflammation
Soap notes - 15/1/22
23/F with multiple joint swellings
S- pain and swelling decreased in B/L UL
Limping gait (+)
ROM at right shoulder
O-
O/E-
Pt is c c c
Temp- afebrile
Bp- 100/70 mmhg
PR- 74bpm
RR- 16cpm
SPO2- 99%
CVS- S1 S2 heard
Rs- BAE+
CNS NFND
P/a- soft non tender
A- RHEUMATOID ARTHRITIS with MCHC ANEMIA WITH CHRONIC GENERALIZED GINGIVITIS
P-
T.PREDNISOLONE 10mg po/od
T. FOLIC ACID 5mg PO/OD
T. METHOTREXATE 7.5MG weekly once
T. NAPROXEN 250MG PO/OD
CHLORHEXIDINE mouthwash (twice a day)
STALIN gun paint (twice a day)
17/1/22
Xray right shoulder AP AND AXIAL VIEW
23/F with multiple joint swellings
S- pain and swelling decreased in B/L UL
Limping gait (+)
ROM at right shoulder
O-
O/E-
Pt is c c c
Temp- afebrile
Bp- 100/70 mmhg
PR- 74bpm
RR- 16cpm
SPO2- 99%
CVS- S1 S2 heard
Rs- BAE+
CNS NFND
P/a- soft non tender
A- RHEUMATOID ARTHRITIS with MCHC ANEMIA WITH CHRONIC GENERALIZED GINGIVITIS
P-
T.PREDNISOLONE 10mg po/od
T. FOLINIC ACID 5mg PO/OD
T. METHOTREXATE 7.5MG weekly once
T. NAPROXEN 250MG PO/OD
T. OROFER XT PO/OD
CHLORHEXIDINE mouthwash (twice a day)
STALIN gun paint (twice a day)
18/1/22
DEPARTMENT OF DERMATOLOGY REFERRAL I/V/O HAIR FALL SINCE 10 MONTHS, AGGREGATED SINCE 2-3 DAYS.
DX- PEDICULOSIS CAPITIS
ADVISED- 1.PERLICE 1% LOTION (1ST DAY AND 8TH DAY)
2. T. TECZINE 10MG PO/SOS
posted by Pranati. V @ January 13, 2022
<< Home