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CH.Snehitha

Roll no.31

5th semester

July 5, 2022

GENERAL MEDICINE.

CASE REPORT: A 49year old female patient resident of west bengal and farmer by occupation came to the OPD with chief complaints of pain in multiple joints and headache.

HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic 10 years back.

C/o pain in shoulder joint, ankle joint, mcp and mtp joints,pip joint, wrist, elbow and knee joints since 10 years. (More in the morning).

C/o neck pain radiating to both upper limbs since 10 years

C/o on and off fever since 10 years

C/o head ache and nausea since 10 years.

(Vomiting follows headache)

HISTORY OF PAST ILLNESS: not a k/c/o HTN, DM, EPILEPSY,  TB, ASTHMA, CAD, CVD.

f/u/o and Polyarthralgia.

TREATMENT HISTORY:  

Nothing significant.

PERSONAL HISTORY:

Age: 49 years

Occupation: Farmer

Married

Diet: mixed

Loss of appetite

Disturbed sleep. Wakes up 3-4 times in between as her head aches. Takes PARACETAMOL as it subsides her headache and helps to sleep better.

Bladder movements: Polyuria. 15-20 times/day

Bowel movements: Constipation. Defecates once in 2-3 days.

No addictions.(smoking/alcohol consumption)

MENSTRUAL HISTORY:

Regular monthly periods

Bleeding stops in 2-3days.

FAMILY HISTORY : 

No history of diabetes, hypertension, asthma, TB, CAD, CVD.

PHYSICAL EXAMINATION: 

• GENERAL EXAMINATION : 

Patient is conscious, coherent and co-operative

Well oriented to time, place, person.

Moderately built and Moderately nourished.

No signs of pallor, icterus, clubbing of fingers or toes, lymphadenopathy, malnutrition and dehydration. 

Oedema of feet -ve.

VITALS: 

Temp- afebrile.

Pulse rate - 78 bpm.

Respiration rate- 17/min

Bp- 120/80 mm hg.

Spo2: 98%

• SYSTEMIC EXAMINATION: 

CVS: 

S1,S2 ++ 

No Murmurs

No Thrills

RESPIRATORY SYSTEM: 

Dyspnoea - no

Position of trachea - Central 

Breath sounds - normal vesicular breath sounds

ABDOMEN : 

Shape of abdomen - scaphoid 

Tenderness - no

Palpable mass- no 

Hernial orifices - normal 

Free fluid - no 

Bruits- no 

Liver- not palpable 

Spleen - not palpable. 

Bowel sounds - yes. 

CNS: 

Level of consciousness- conscious 

Speech- normal 

Signs of meningeal irritation- none 

INVESTIGATIONS ORDERED:

• Hemogram
• Renal function tests
• Liver function tests
• ESR
• ECG
• CXR (PA view)
• X-RAY of hands and wrists- bilateral (AP and lateral)

 PROVISIONAL DIAGNOSIS: 

RHEUMATOID ARTHRITIS.

and Anemia of chronic disease

TREATMENT:

(1.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

* Ophthalmology referral advised.

   Ophthalmologist impression: mild glaucomatous disc changes in both eyes. Fungus examination every 6 months.

(2.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

(3.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

(4.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

7. Tab OROFER XT 100mg PO/OD

(5.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

7. Tab OROFER XT 100mg PO/OD

(6.7.2022)

1. Tab PREDNISOLONE 10mg OD

2. Tab METHOTREXATE 7.5mg once a week (Friday)

3. Tab FOLIC ACID 5mg PO OD (Saturday)

4.Tab PAN 40mg PO OD

5. Tab NAPROXEN 250mg PO TID 5days

6. Tab AMITRYPTALIN 10mg PO/HS

7. Tab OROFER XT 100mg PO/OD

(7.7.2022)

*referred to general surgeon as the patient complaints of pain in b/l breast.

General surgeon impression: Both breast soft, with vague tenderness, NO MASSES felt and NO NIPPLE DISCHARGE. Suspects FIBROADENOSIS. Ordered Mammograph.

*NOTE: THIS IS AN ONGOING CASE. I'LL BE EDITING AND UPDATING THE CASE DETAILS IN THIS E-LOG AS AND WHEN NEEDED.