51 year old with joint pains and back pain since 1 year

 Chief complaints:- 

C/o B/L knee pains since 4 years 

Lower back ache since 1 year

B/L UL and LL muscle pains and multiple joint pains since 4 months 

B/L pedal edema since 3 months 

Difficulty in swallowing since 3 months 

Hopi :

Patient was apparently asymptomatic 4 years ago, then she developed B/l knee pain insidious in onset and gradually progressive which gets aggrevated on doing and relieved on rest 

Patient had h/o fall in 1 year ago due to slippage in the bathroom, sustained injuries to the lower back , she was on conservative management.

4 months ago she had a swelling and pain in all the joints of B/L upper limbs and lower limbs and developed fever for 3 days , lower grade rest a/w chills and rigors 

B/L pedal edema since 3 months upto ankle jt and non pitting type 

Occassional H/o difficulty in swallowing more to solids 

H/o constipation ( passes stools once in 3 days after taking syrup.

General Examination:

Patient is conscious coherent and cooperative 

pallor - present 

edema - present 

No icterus , clubbing, cyanosis,lymphadenopathy , 

Vitals : 

BP- 130/80 mmhg

PR -76 bpm

RR-14 cpm

Spo2- 98 % @ RA

Temperature- 98.6 ⁰F

Systemic examination:-

Cvs: s1,s2 heard ,no Murmurs

Rs: BAE, NVBS

P/A: soft, non tender ,bowel sounds present 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, 

motor system

Power both LL is 4-

              Both UL is 4-

Tone both UL

              Both LL

Sensory system : normal

Gcs: E4,V5,M6

 Reflexes:

      R L

B - -

T - -

S - -

K - +

A - -

P flex flex

Investigations:-

Diagnosis:

SEROPOSITIVE RHEUMATOID ARTHRITIS with PARAPARESIS 2⁰ to L1- L3 # with k/c/o HTN, GERD, BRONCHIAL ASTHMA 

Treatment:- 

1)Tab. METHOTREXATE 7.5mg once weekly ( next dose 11/5/23 )

2)Tab. FOLIC ACID 5 mg PO/ODNext after methotrexate dose.

3)Tab. WYSOLONE 10 mg PO/OD

4) Tab. PAN 40 mg PO/OD