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A CASE OF Rheumatoid arthritis

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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

A 45 year old gentlemen who was a farmer from suryapet came to the hospital with chief complaint of

Cheif complaint
Decreased urine output
Right sided lower abdominal pain  since 10 days

History of presenting illness
Patient was apparently asymptomatic 4 years back

Then he developed pain in right knee which was  gradual ,progressing, nonradiating, dull in nature
Pain was not aggravated while sitting or bending

After 1 month there was decrease in knee pain and then ankle started to pain
There was involvement of one joint after the another each joint pain used to last for 10 days

There was involvement of following joints
Knee 
ankle
Shoulder
Elbow
Wrist
MIP
There was no involvement of proximal and distal interpharengeal joints
No involvement of back or neck

He visited a rmp after 3 months where he was given medication? 
Took one per day when it hurts

There was no time when all joints were involved
There have been 2 hospital admission
First when he visited ge was treated as gouty arthritis and on investigation was done his hb was found to be 3
He was treated with B12 
Then he visited our hospital again with regarding his joints  for which he was admitted for 5-6 days 
His hb was again found to be 3.5 which was now treated as dimorphic anemia with both iron and folic acid tablets
He is not using the given medication
He used medication for pain a month and the pain subsided for 1 month

Then the pain gradually increased by 6 months
He also stopped going to work when he was admitted and has not gone since

There are also white patches on fore head going into the hair since 4 years

There is also Increased frequency of micturation since 3-4 months


Past history

N/k/c 
Diabetes
Hypertension
Tuberculosis
Asthama

Daily routine
 2 yrs back -
 
 wake up at 4-5am
 Eat rice 
 11am-12pm - work
 2-3pm lunch box at work
 8-9pm come back to home 
 Dinner-9pm
 Watch tv 
 9:30-10pm- sleep


1yr back-

Wake up at 7am
Drink plain milk
Takes rest
9:30-10am- rice( less than before)
Time pads
2-3pm-lunch
Sleep
4-5wake up
Time pass
8pm-dinner
Sleep

PERSONAL HISTORY:
Diet-1yr back stopped nonveg because doctor told to stop
Decreased appetite
Decreased micturition-since 3-4months 
Before 2-3hrs once 
Normal bowel movements
Normal sleep
Addictions-Toddy,alcohol-occasionally 50ml stopped 2 yrs back


FAMILY HISTORY:-
No significant history

Provisional diagnosis
Anemia 2 to? 
Seronegative? RA
Chronic kidney disease 2 to Analgesic nephropathy
Cholelithiasis

GENERAL EXAMINATION:-

Vitals:-
Temp- afebrile
PR:91BPM.
Bp:100/80mm Hg
Spo2 : 100%
GRBS: 84 MG%

PALLOR present

No ICTERUS
NO CYANOSIS
CLUBBING present
NO KOILONYCHIA 
NO LYMPHADEONAPTHY
EDEMA present pitting type till ankle






SYSTEMIC EXAMINATION:-

A. Cardiovascular system 
S1 S2 HEARD
NO MURMURS.
B. Respiratory system 
NVBS heard
BAE +
TRACHEA CENTRAL.


C. Per abdominal examination 
SOFT
Scaphoid
Spleenomegaly
No hepatomegaly
Mild tenderness on Right hypochondrium
D. Central nervous system:-
Conscious 
Speech normal
Cranial nerve-NAD
Cerebellar system-NAD
No signs of meningial irritation/ meningitis


Joints

Joint examination
Hands-Swan neck deformity except little finger
Knee-local rise of temperature,crepitus
Elbow-mild rise of temperature,crepitus





Investigation

Day 1


https://youtu.be/0Ns2QzOlxBY











Treatment

Day 1
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB PAN 40mg PO/OD

Day 2

TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB PAN 40mg PO/OD
 TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY

DAY 3

TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD


DAY 4
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD

Day 5
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD

Day 6
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD

Day 7
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD

Day 8
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD

Day 9
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD
TAB DOLO650 mg/PO/TID
TAB MONOCEF 1gm/IV/BD



Day 10
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD
TAB DOLO650 mg/PO/TID
TAB MONOCEF 1gm/IV/BD


Day 11
TAB LIMCE PO/OD
vitals monitoring
TAB ULTRACET 1/2 tab PO/QID
TAB PREDNISOLONE 10mg PO/OD
TAB METHOTREXATE 7.5 mg/PO/WEEKLY ONCE
TAB FOLIC ACID EVERY ALTERNATIVE DAY
Syrup CREMAFFIN 15 ml /PO/HS
INJ METHYLCOBALAMINE 1500micrograms/IV/30MIN IN 100ml
TAB F6BUXO STAT 40 mgPO/OD
TAB PAN 40mg PO/OD
TAB DOLO650 mg/PO/TID
TAB MONOCEF 1gm/IV/BD

Day 12

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