A 43 year old female presented with weakness of upper limb and lower limb.

Chief complaints: weakness of upper limb and lower limb.

History of present illness: Patient was apparently asymptomatic 1 year back the  developed joint pains and stiffness in the upper limb in the fingers. Then she developed flexion deformity in the metacarpals. 

Past history : No similar complaints in the past. Not known case of diabetes, hypertension, Asthma, TB, thyroid.

Personal history : 
Diet:mixed
Appetite: Normal
Sleep : adequate 
Bowel and bladder : regular 
Addictions: none 

Family history: No similar complaints in the family

General physical examination :
Patient is conscious, coherent and Cooperative, thin built and nourished.

Pallor : absent 
Icterus: absent 
Cyanosis: absent 
Clubbing : absent 
Lymphadenopathy : absent
Edema: absent

Systemic examination: 
CVS : S1 S2 heard

RESPIRATORY SYSTEM: Normal vesicular breath sounds heard. 

CNS: No focal neurological deficits 

Abdomen: Soft , non tender.

Investigation: 
USG: 

ECG:
Diagnosis : Rheumatoid arthritis.

Treatment: 
Tab dolo
Tab methotrexate 
Tab folic Acid 
Inj neomal 





Comments

Post a Comment

Popular posts from this blog

30year female presented with shortness of breath since 2 days

Image
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 box History of presenting illness:  Patient was apparently asymptomatic till 2017 then she had loss of patches of hair ,joint pains and oral ulcers and was diagnosed with Systemic lupus erythematosis.  Then she developed pedal edema and renal biopsy was done and diagnosed  with  lupus nephritis and was on conservative management. Patient was initiated on hemodialysis since February 2023 and is on MHD(maintenance hemodialysis).  Patient presented with shortness of breath since 2days which
Read more

A 50 year old male with acute abdomen

Image
 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.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 diagnosis and treatment plan The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  CO
Read more

77 year old male with SOB

Image
  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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT . A 77 year old male, fruit vendor by occupation came to opd with chief complaints of shortness of breath since one week. HOPI : Patient was apparently asymptomatic two years ago then he developed bilateral knee pain for which he went to the hospital and incidently diagnosed with hypertension. After which he was started on antihypertensives which he did not use regularly. Two months ago patient developed shortness of breath which was insidious in onset and gradually progressive as dyspnea appeared on doing  minor physical activity and progressed to SOB on walking for small distances( Grade 2 to Grade 3) a
Read more