27 year old female patient presented with the complaints of joint pains affecting her daily activities
27 year old female patient presented with the complaints of joint pains affecting her daily activities
20/11/21
March 2019
After 6 hours of sleep in the night she experienced pain , swelling , mild rise of temparature with restriction of movement of left elbow joint : slight flexion of elbow joint which lasted for one and half year
Visted orthopedician and was on Tab PCM and ointment /gel and Tab Pan for one month but no improvement .
(She is pointing pain towards lateral epicondyle, capitulum, radial head)
September 2020
she went for physiotherapy for right elbow joint pain
Then 3-4 days later she started experiencing pain in the right ankle joint
At tarsal bones and fibula tibia joints ?subtalar, ? Tibiotalar.
Pain redness swelling over joint present.
Pain was progressing and radiating from lateral to medial side and then to plantar aspect of foot
Not relieved on medication even after 15 days
Feb 2021
she started experiencing pain over right wrist joint ? Arthritis She had been to a neurologist it didnt subside
Along with that she had tremors of right hand
July 2021
arthritis of left wrist and ankle .
Pattern : left elbow - right ankle - right wrist - left wrist - left ankle
Among all right wrist she is experiencing more pain.
Difficulty in walking she told that she is experiencing since 2020 sept after she experienced right ankle joint pain.
No sensory symptoms
Past history
Not a known case of DM, HTN, Asthma, Epilepsy, TB, CVD
Personal History
Diet - mixed
Appetite - normal
Bowel and bladder - regular
Sleep - adequate
No addictions , allergies
Family History - Insignificant
General examination
Patient - conscious, coherent , cooperative
Well oriented
No signs of pallor, icterus,cyanosis, lymphadenopathy ,clubbing, edema
Temperature - afebrile
Pulse - 90bpm
Blood pressure - 100/60 mmHg
Respiratory rate - 16cycles
Systemic examination
CVS - S1, S2 heard
Respiratory system - NVBS, BAE+
Per abdomen -soft and non tender
CNS - NFND
Examination of joints
Wrist joint : flexion limited on both sides
Extension markedly limited ( Rt>left)
Ulnar deviation : limited
Radial deviation : limited
Pronation and supination: partially able to do
Ankle joint: plantar flexion markedly limited on right side than left
Dorsiflexion able to do
Eversion markedly limited on right side
Inversion able to do with difficulty
The joint involved earlier has progressed to greater limitation of movements than the one involved later.
Pain is usually more in the morning and decreased as day progresses.
She also complaints of pain in the buttock region intermittently since 4 years
Dx - Chronic inflammatory polyarticular asymmetric
? Spondyloarthropathy
Previous reports 3months back RA FACTOR done , it was negative
Treatment
Tab ultracet 1/2 QID
Tab pregaba 75 po OD
Tab Indocap 75mg pO BD
SOAP NOTES
14/11/21
27 year old female
S
No fresh complaints
O
PR: 69 BPM
BP: 110/70 mmHg
Spo2 :98 @ room air
Temp : 97.6 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? FIBROMYALGIA
P
Tab.PREGABA 75 MG / PO/OD (X-X-1)
TAB.NAPROXEN 250 MG /PO/TID
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.ULTRACET 1/2 TAB QID
TAB.PREDNISOLONE 10 MG /PO/OD (X-X-1)
physiotherapy
15/11/21
SOAP NOTES ( ward case)
27 year old female
S
C/o pain in the rt wrist
O
PR: 78 BPM
BP: 110/70 mmHg
Spo2 :98 @ room air
Temp : 97.6 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? RHEUMATOID ARTHRITIS
P
Tab.PREGABA 75 MG / PO/OD (X-X-1)
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.ULTRACET 1/2 TAB QID
TAB FOLIC ACID 5MG PO/OD WEEKLY ONCE
TAB METHOTREXATE 7.5MG PO/WEEKLY ONCE
17/11/21
SOAP NOTES ( ward case)
27 year old female
S
C/o pain subsides for 6-8 after taking medication and again she complaining of pain
O
PR: 78BPM
BP: 100/70 mmHg
Spo2 :98 @ room air
Temp : 99.0 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? Rheumatoid arthritis
P:
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.PCM 650MG PO/SOS
TAB.ULTRACET 1 TAB PO/SOS
TAB FOLIC ACID 5MG PO/OD WEEKLY ONCE
(ONLY ON MONDAY)
TAB METHOTREXATE 7.5MG PO/WEEKLY ONCE
(ONLY ON SUNDAY)
18/11/21
SOAP NOTES ( ward case)
27 year old female
S
No fresh complaints
Feeling better
O
PR: 82BPM
BP: 100/70 mmHg
Spo2 :98 @ room air
Temp : 98.2 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? Rheumatoid arthritis
P:
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.PCM 650MG PO/SOS
TAB.ULTRACET 1 TAB PO/SOS
TAB FOLIC ACID 5MG PO/OD WEEKLY ONCE
(ONLY ON MONDAY)
TAB METHOTREXATE 7.5MG PO/WEEKLY ONCE
(ONLY ON SUNDAY)
19/11/21
SOAP NOTES ( ward case)
27 year old female
S
C/O FEVER 1 EPISODE IN THE NIGHT
O
PR: 85BPM
BP: 100/70 mmHg
Spo2 :98 @ room air
Temp : 98.9 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? Rheumatoid arthritis
P:
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.PCM 650MG PO/TID
TAB.ULTRACET 1 TAB PO/SOS
TAB FOLIC ACID 5MG PO/OD WEEKLY ONCE
(ONLY ON MONDAY)
TAB METHOTREXATE 7.5MG PO/WEEKLY ONCE
(ONLY ON SUNDAY)
TAB DULOXETINE 20MG PO OD
SOAP NOTES ( ward case)
27 year old female
S
C/O no fresh complaints
Fever subsided
O
PR: 88BPM
BP: 110/70 mmHg
Spo2 :98 @ room air
Temp : 97.5 °F
CVS: S1S2 heard
RS: BAE + , NVBS
P/A : SOFT ,NON TENDER
A
? SPONDYLOARTHROPATHY
? Rheumatoid arthritis
P:
TAB.RANITIDINE 150 MG /PO/OD (BBF)
TAB.PCM 650MG PO/TID
TAB.ULTRACET 1 TAB PO/SOS
TAB FOLIC ACID 5MG PO/OD WEEKLY ONCE
(ONLY ON MONDAY)
TAB METHOTREXATE 7.5MG PO/WEEKLY ONCE
(ONLY ON SUNDAY)
TAB DULOXETINE 20MG PO OD
PLANNING FOR DISCHARGE
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