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gm case

GM e log
July 08, 2022
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 is welcome.
IMMANI AASRITHA

Roll no.49

5th semester

July 10, 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

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 5daysTab 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.

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