A 34 year female patient appears to be well nourished and well built is conscious,coherent and well oriented to time place and person came to opd on 27th may 2022
Patient's previous complaints of having joint pains have been controlled with the use of prednisolone and methotrexate. Patient is apparently normal and complains about having back pain at level of lower thoracic vertebrae and pain at weight bearing region of ankle after working for longer hours in sitting position.she also noticed her gradual gain in weight after a year on therapy.
Patient has been previously diagnosed with rheumatoid arthritis.and is not a known case of diabetes mellitus/HTN/THYROID/seizure
Family history-no h/o similar complaints in family
Personal history-
Patient has a habit of chewing pan(chews 20per day)
patient does not smoke nor drink alcohol.
Dietary history- normal
Bowel and bladder- regular and normal
General examination
No Pallor
No Icterus
No Clubbing
No Cyanosis
No Lymphadenopathy
No Edema
VITALS-
AFEBRILE ON TOUCH
BP - 130/90 mm hg
HEART RATE 100bpm
Respiratory rate-16cpm
P/E
CVS-S1,s2 heard
RS- BAE+
CNS-pt is c/c/c
TONE
Tone:
R-UL-N, L-UL- N
R- LL- N, L- LL- N
Power:
R-UL:5/5
L-UL:5/5
R-LL:5/5
L-LL:5/5
Reflexes:R, L
B: 2+ , 2+
T: 2+, 2+
K: 2+,2+
Abdomen-
Inspection-flabby and distnded abdomen,no engorged veins.
Percussion-tympanic
No fluid thrills,shifting dullness
Palpation-no tenderness and no abdominal mass,
Auscultation- normal bowel movements
Passes urine 8-9 times a day
PROVISIONAL DIAGNOSIS: RHEUMATOID ARTHRITIS
RX:
1)TAB.METHOTREXATE WEEKLY ONCE PO
2)PREDNISOLONE 5MG--- 2.5MG PO
3) TAB.FOLIC ACID 5MG PO
