A 58 YR F C/O PAIN IN SMALL AND LARGE JOINTS
LEARNER REPORT
"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 comments box.
I HAVE BEEN GIVEN THIS CASE TO SOLVE IN AN ATTEMPT TO UNDERSTAND THE TOPIC OF ''PATIENT CLINICAL DATA ANALYSIS'' TO DEVELOP MY COMPETENCY IN READING AND COMPREHENDING CLINICAL DATA INCLUDING HISTORY,CLINICAL FINDINGS,INVESTIGATIONS AND COME UP WITH A DIAGNOSIS AND TREATMENT PLAN.
HISTORY OF PRESENTING ILLNESS -
A 58 YR OLD F PT. WHO IS A PROFESSOR IN A UNIVERSITY CAME TO CASUALITY WITH CHEIF COMPLAINS OF PAIN IN THE SMALL JOINTS , LARGE JOINTS SINCE 8 MONTHS .
PATIENT WAS APPARENTLY ASYMPTOMATIC 8 MONTHS BACK THEN SHE OBSERVED PAIN IN THE SMALL JOINTS WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE PRESENT THROUGH OUT THE DAY AGGREVATES ON DOING WORK AND SHE GRADUALLY FORGETS ABOUT THE PAIN AND THERE ARE NO RELIEVING FACTORS SHE ALSO COMPLAINTS OF MORNING STIFFNESS WITH RESTRICTION OF PAINFUL MOVEMENTS .
SHE COMPLAINS OF RADIATING TO LARGE JOINTS WHICH DISTURBS HER SLEEP.
C/O MORE PAIN IN THE RT. WRIST JOINT ALONG WITH SWELLING FOR WHICH SHE USED MEDICATION FOR A FEW DAYS . PAIN GRADUALLY PROGRESSED FROM SMALL JOINTS TO LARGE JOINTS AND CURRENTLY HAVING PAIN DURING LIFTING OF HER SHOULDER.
C/O NOT ABLE TO WRITE
HISTORY OF PAST ILLNESS -
H/O SURGERY DONE 2YRS BACK TO THE LEFT WRIST DUE TO A FALL
N/K/C/O DIABETIS MELLITUS , HTN
PERSONAL HISTORY -
DIET - MIXED
APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENT- REGULAR
SLEEP - ADEQUATE
ADDICTION
FAMILY HISTORY - NO SIGNIFICANT FAMILY HISTORY
DRUG HISTORY - NO KNOWN DRUG ALLERGIES
GENERAL EXAMINATION-
PT. IS CONSCIOUS, COHERENT AND COOPERATIVE AND WELL ORIENTED TO HER SURROUNDINGS . SHE IS MODERATELY BUILT AND NOURISHED
NO PALLOR, NO ICTERUS , NO CLUBBING , NO CYANOSIS, NO LYMPHADENOPATHY
VITALS -
TEMP - AFEBRILE
BP - 120/80 MMHG
PR - 84 BPM
RR - 14 CPM
SPO2 - 98% @RA
SYSTEMIC EXAMINATION -
CVS - S1 , S2 HEARD
RS - BAE +
CNS - NAD
P/A -SOFT , NON TENDER
DVL REFERRAL
FEMALE PATTERN ALOPECIA + TELOGEN EFFLUVIUM
CLINICAL IMAGES -
ON 19/7/21
ON 3/3/22
PROVISIONAL DIAGNOSIS -
SERONEGATIVE RHEUMATOID ARTHRITIS + FEMALE PATTERN ALOPECIA + TELOGEN EFFLUVIUM
TREATMENT -
1) TAB. PREDNISOLONE 10MG / PO / OD
2) TAB . METHOTREXATE 75MG ( WEEKLY ONCE ) / PO / OD
3) TAB . FOLVITE 5MG / PO / OD ( WEEKLY ONCE ) ALTERNATE DAY
INVESTIGATIONS
HEMOGRAM -
Hb - 9.6 mg/dl
PCV - 29.9
RBC - 3.39
PERIPHERAL SMEAR -
NORMOCYTIC NORMOCHROMIC
WBC - WITHIN LIMITS
PLATELET - ADEQUATE IN NUMBER AND LIMITS
RA FACTOR - NEGATIVE
LFT -
ALP - 212
DB - 0.24
S
NO FRESH COMPLAINS
O
PT. IS CONSCIOUS , COHERENT , COOPERATIVE
VITALS
TEMP - AFEBRILE
BP - 120/70MMHG
PR - 86 BPM
RR - 15 CPM
RS - BAE +
CVS - S1 S2 +
PA - SOFT , NON TENDER
A
? POLYARTHRITIS , ? RA
P
1) TAB . METHOTREXATE (WEEKLY ONCE ) / OD
2) TAB . FOLVITE (WEEKLY ONCE ) /OD
3) TAB . PREDNISOLONE PO/OD
4 ) TAB . NAPROXEN
