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Abstract: This patient, 55 years old, developed generalized joint pain half a year ago, and took diclofenac sodium extended-release tablets and prednisone acetate tablets for drug treatment outside the hospital, but did not play a significant effect. However, due to the special nature of the disease, she still needs to take medication intermittently.
Basic information】Female, 55 years old
Type of disease】Rheumatoid arthritis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Time of Consultation】May 2019
Treatment plan】Medication (Prednisone acetate tablets, methotrexate tablets, rheumatoid polysaccharide tablets)
Treatment period】5 days of inpatient treatment, 3 months of outpatient follow-up
Effectiveness】Improvement and relief of symptoms
I. Initial consultation
The patient, a 55-year-old female, developed generalized joint pain six months ago for no apparent reason, with the most severe pain in the joints of both hands and the left knee, but did not attract the patient’s attention. The physical examination performed at the outpatient clinic today indicated that the proximal interphalangeal joints of both hands were enlarged; the left knee joint was swollen with limited movement; and the left lower extremity had moderate finger sunken edema, which was consistent with the signs of rheumatoid arthritis. The patient was given an X-ray examination, which showed that the bone density of some joints was reduced, small capsular bone destruction was seen, the joint space was narrowed and disappeared, and the joint surface was blurred. The patient was given a routine blood test, which showed an increased erythrocyte sedimentation rate. Combined with the patient’s complaints, he was initially diagnosed as “rheumatoid arthritis” and admitted to the hospital.
II. Treatment history
After introducing the examination results to the patient and his family, we explained the treatment plan and decided to first use low-dose prednisone acetate tablets in combination with methotrexate tablets and rhodopsin tablets for treatment. During the medication period, the patient’s condition was continuously observed, and they were instructed to inform the patient in time if they had any uncomfortable symptoms. After 5 days of hospitalization, the patient’s symptoms improved, so he was discharged from the hospital and continued to take medication.
III. Treatment effect
The patient was treated in hospital for 5 days, and the results of the review indicated that the inflammatory indexes decreased, indicating that this treatment plan was effective for the patient. The patient was discharged and asked to continue taking the medication for 6 weeks, and returned to the outpatient clinic for a follow-up examination. The results of the follow-up examination indicated that the number of joint induration, pain, joint swelling, and erythrocyte sedimentation rate had decreased, and the patient felt that the symptoms of pain in the joints of both hands and the left knee had been significantly reduced.
IV. Notes
I was pleased with the patient’s improvement, but I reminded her that she should also pay attention to her daily diet and prohibit eating fatty foods such as fatty meat, offal, and barbecue to prevent being overweight and aggravating her left knee pain. In addition, although the results of this follow-up examination were relatively good, we still should not take it lightly, because rheumatoid arthritis cannot be cured at present and requires lifelong intermittent treatment, after which the patient needs to come for a follow-up examination every three months, and if the condition is subsequently stabilized, the follow-up examination can be extended to once a page.
V. Personal insight
Patients with rheumatoid arthritis should be diagnosed and treated early, and if a treatment plan does not work well, they should seek medical attention and follow medical advice to change the treatment plan. The patient in this article did not pay attention to this disease in the early stage of treatment, and did not promptly explain to the doctor according to his own situation, to a certain extent, there is a certain negative impact on the treatment of the disease itself, but the good thing is that it did not cause serious consequences, and in the follow-up treatment, the compliance is better, so the disease has been controlled.