Case of rheumatoid arthritis -faizal. M(rollno.44)

Hi,This is faizal. M 3 rd semester students.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio

Chief complaint : A 49 years old female patient who is agriculture labour in occupation came to opd with chief complaint of multiple joint pain since 10years with stiffness in morning. 

History of present illness:Patient was apparently asymptomatic 10 years ago then she started having joint pains. she is anemic.The patient had complained of swellings in the leg associated with the joint pain. The patient had also complained of Headache associated with the joint pain and fever which seemed to be on and off . The patient complained of vomiting. The patient said that joint pains,fever and Headache reduced after vomiting . The patient also complained of morning stiffness. 

Past history:No history of diabetes,hypertension, epilepsy ,CAD , tuberculosis and asthma
Drug history:




Family history:No significant family history of present illness
Personal history:The patient takes a vegetarian diet . Sleep cycle is irregular . Loss of appetite . Urination is 15 times per day . Frequency of bowel movements is once every 2-3 days. Menstrual cycle occurs regularly but only lasts for two days. No history of any addiction. 

General examination:Patient is conscious, coherent and cooperative.
BP-120/80mm Hg
PR-78/min
pallor ++,no cyanosis,no lymphadenopathy,no edema


Systemic:CVS-S1,S2 heard


Finding:
                                    ECG  report














Diagnosis:This is a case of rheumatoid arthritis

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