23/F P3L3 with multiple joint swellings
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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
