E.L. 61/F

• DOB: February 5, 1948 / Manila• Valenzuela, MM• Catholic• Separated• 2 children

• Chief Complaint: FOLLOW-UP

1995 Diagnosed with Rheumatoid Arthritis•Morning stiffness•Symmetrical arthritis•Arthritis of 3 or more joint areas

Ankle Knee Elbow

Meds: Methotrexate PrednisoneCalcium carbonate (Calci-Aid)Hydroxychloroquine sulfate (Plaquenil) Folic AcidCelecoxib (Celebrex) or Naproxen

Sodium (Flanax) – if (+) joint pains, usually taken 3x a week

Therapies: Every other day for 6 monthsHot Water (45 mins.)Wax (45 mins.)Exercise

Compliant with the medications Improved, stable, can walkWith regular, monthly check ups

2001 Was lost to follow-upMaintained on:

Hydroxychloroquine sulfate (Plaquenil)Prednisone Celecoxib (Celebrex) or Naproxen

Sodium (Flanax) – if (+) joint pains, usually taken 3x a week

2004 (+) Hand deformitiesWheelchair-borne

Feb. 2008

Blurring of L eyeNo consultation doneNo medications taken

Feb. 2009

Blurring of L eye(+) Redness(+) StingingNo consultation doneNo medications taken

March2009

Check up for L eye(+) Blurring(+) Redness(+) Stinging(+) “Puwing”

Meds prescribed:Ciprofloxacin (Ciloxan) E/D – Instill to both eyes every 4 hrs for 1 weekDextran + Hypromellose (Art. Tears Solution) E/D – Instill to both eyes every 2-4 hrsSulodexide 250 LSU/cap (vessel Due F) 1 cap 1x a day for 15 daysLatanoprost E/D (Xalatan) – Instill to L eye every 6pm daily

Apr. 3,2009

Follow up check up for L eye(+) Slight relief

Meds prescribed: Same as in March 24, 2009 +Eye supplement (Ocuvite) – 1 gel cap 1x a day

Apr. 16 Follow up check up for L eye(+) Slight relief

Was told to continue previous medications +Betaxolol HCl E/D (Betoptic S) - Instill to both eyes 2x a day, alternate with Latanoprost E/D every other dayDeproteinized Calf Blood Extract

(Solcoseryl ) Eye Gel – Instill to both eyes every 6 hrs.

May 1 Follow up check up for L eye(+) Redness(+) Stinging(+) Pricking pain(+) Glare in R eye

MedicationsCiprofloxacin (Ciloxan) E/D – Instill to both eyes every 4 hrs for 1 weekDextran + Hypromellose (Art. Tears Solution)

E/D – Instill to both eyes every 2-4 hrs

Also sought consult for tonsillitis

Medications given and taken:Co-amoxiclav 375 mg 21 tabs – 1 tab 3x a day for 7 daysParacetamol (Rexidol) tab 1 tab every 4hrsGargle with Bactidol or Betadine mouthwash

May 4

May 1

Relief of tonsillitis

Continued with the medications

May 14 Follow up check up for eyes

Previous medications stopped except for Betaxolol HCl E/D and Deproteinized Calf Blood Extract (Solcoseryl) Eye Gel

Follow up check upMedications given:

Latanoprost E/D (Xalatan) with Betaxolol HCl E/D (Betoptic S) to consumeLid scrubbing 2x a day with Ciprofloxacin (Ciloxan) E/D Dextran + Hypromellose (Art. Tears) to both eyes every 2-4 hrsHypotears Eye Gel 3x a dayConsume Sulodexide 250 LSU/cap (Vessel Due F) then shift to Almitrine bismesylate 30 mg, Raubasine 10 mg (Duxaril) for 1 month

Was referred to eye center of choice but did not go to any

Also sought consult because of the fever of 2 days duration

CBC done – WBC and platelets normal

May 21

May 20 Fever (38.2-38.3°C)Took Paracetamol (Tempra) which provided relief

(+) Swelling above the R eye(+) Heavy, can’t fully open the R eye(+) Redness(+) Slight pain(+) Dryness(-) Tears(-) Discharge(+) Blurring of L eye(-) Fever

Brought to the UST ER and advised for work-upPrevious eye medications were stoppedHot compress applied which provided slight reliefDx: periorbital cellulitis

June 28

Left ear(+) Pain(+) Swelling(+) Hearing loss(+) Tinnitus

June 27

Medications given for 1 week:Betahistine dihydrochloride (SERC) 16

mg/tab – 1 tab 2x a day prn for dizzinessCloxacillin 500 mg /tab – 1 tab every 6

hrs for 7 daysTobramycin eye drops (Celsus) – 1 drop

both eyes every 4 hrsHypromellose (Genteal) Eye drops – 1

drop both eyes every 4 hrsCinnarazine (Stugeron forte) 75 mg/cap – 1 capsule once a day

Hydrogen peroxide – Apply 3 drops on each ear 3 x a day until follow up

June 29

June 28

Request for CBC, urinalysis, Crea, ALT, ESR given

Prescribed with Prednisone 5mg/tab; Hydroxychloroquine sulfate 200mg/tab; and Calcium carbonate (Calci-Aid) (1-0-1)

CXR done

Left ear drainage doneHearing regainedL ear problem resolved

July 8

July 3

Follow up check up for

RA

Family History

• Mother – (+) DM, HPN; died due to heart attack

• Father – (+) HPN; died due to heart attack• 2 sisters – heart attack• Sister – cervical mass• (-) TB• (-) Cancer

Past Medical History

1990- mastectomy R breast• 16 cysts + whole breast removed• Biopsy normal• Had mammogram 10 years ago – normal

Unrecalled immunizations

Personal and Social History

• Former beauty consultant• Retired since 1995• Wakes up at 4-5am, regular sleep pattern• Diet: mixed (meat, fish, vegetables)• (-) smoking, (-) alcohol• (-) use of illicit drugs

FOLLOW UP

• Arthrocentesis on both knees– 12 cc on both knees– Yellowish, turbid

• Intraarticular steroid injection– Dose (?)

Arthrocentesis

Arthrocentesis

Intraarticular steroid injection

FOLLOW UP

• Labs done– Urinalysis• pH 6.0• Specific Gravity 1.010• (-) albumin, sugar• Pus cells 0-2/hpf• Few squamous cells, amorphous urates

FOLLOW UP

• Labs done (7/8/9)– Creatinine– SGPT-ALT

Test Result Reference Range Result Reference

Range

Creatinine 0.58 0.5-1.2 mg/dL 51.3 44.20-106.08 umol/L

SGPT-ALT 11.8 0-31 U/L 11.8 0-31 U/L

CBC Result Unit Reference Range

HGB 125 g/L 120-170

RBC 4.03 x 1012/L 4.0-6.0

HCT 0.36 0.37-0.54

MCV 88.70 U3 87 + - 5

MCH 31.10 pg 29 + - 2

MCHC 35.10 g/dL 34 + - 2

RDW 14.30 11.6-14.6

MPV 7 fL 7.4-10.4

Platelet 514 x 109/L 150-450

WBC 6.60 x 109/L 4.5-10.0

Differential Count Result Reference Range

Neutrophils 0.64 0.50-0.70

Metamyelocytes -

Bands - 0.00-0.05

Segmented 0.64 0.50-0.70

Lymphocytes 0.30 0.20-0.40

Monocytes - 0.00-0.07

Eosinophils 0.06 0.00-0.05

Basophils - 0.00-0.01

ESR

ESR Result Unit Reference Range

Modified Westergren

87.0 MM after 1 hr.

0-20 MM after 1 hr.

Medications

• Prednisone 5 mg/tab – 1-0-0• Hydroxychloroquine sulfate 200 mg/tab – 1-0-1• CaCO3 + D (Caltrate / Calvit) – 1-0-1

• Methotrexate 2.5mg – 3 tablets on Thurs (July 9); 4 tablets on July 16 and every Thursday thereafter

• Folic Acid 5mg/cap – 1 cap M-W-F