35 /F with multiple joint pains

 Patient came to casuality with ,
c/o generalised body pains since 4 months 
A/w pedal edema since 1month
A/w fever ( on and off )

HOPI: 
Patient was apparently asymptomatic 4 months back then she developed severe joint pains involving toes and fingers not a/w swelling , this then was slowly progressing to involve other joints , wrist, elbow, shoulder,knee, and ankle
- pain a/w restriction of movement since 3 months
- stiffness of joints present since 3 months , aggrevated with increased activity 
-stiffness and pain are more in the morning ( after waking up ) and decreasing as the day progressed ( increased again at the night after 7.30pm ) disturbing her sleep quality 
-swelling joints present at the knee and MCP joints since 4 days ( on and off) resolves spontaneously 
-swelling at ankle : Non pitting type , increased when standing and working and decreased at rest
- pt c/o decreased capacity to work due to pain since 4 months 
-No similar complaints in past
-N/K/C/O  DM,HTN,CAD,Asthma,TB,epilepsy 
H/o similar complaints in the family( sister and father) 
VITALS:
temp: afebrile  
Pr : 88/min
Rr: 12/min
Bp : 80/60 mmhg
Spo2 : 99% @ra


S/E:
CVS: S1S2 +
RS: BAE +
P/A : soft, non tender
CNS: NAD
PROVISIONAL DIAGNOSIS:                    RHEUMATOID ARTHRITIS 
TREATMENT GIVEN:
1) TAB.NAPROXEN 250MG/PO/TID
2)TAB.PAN 40MG PO OD 
3)TAB.WYSOLONE 10MG PO BD
4)TAB.METHOTREXATE 7.5mg PO OD WEEKLY ONCE (WEDNESDAY)
5)TAB.FOLIC ACID 5MG PO OD WEEKLY ONCE (THURSDAY)

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