42 Y OLD FEMAL PT 
KO TO  RA   FOR THE LAST   3  YEARS 
2021 she started o have joint pain, no  skin rash m   jointy  swelling   small  joint of te hand 
N oral ulceration 
8  pregancy  2  missed   eye  redness 
Recurrent chest pain 
No abdominal pain 

First was diagnosed  with RA   treated    mtx  vit  d   and prednisone   with clinical improvement 

Last  fall she has  chest pain and  she  stopped her mediation 
Then she started to have   left shoulder pain ,  then  the esr  remains  the same 

Creatinine   rose  to 1.6  before    one months 
Sought medical advie at  dr  saed   then she   underwent  further evaluation   and she  found to have   positive   ANA   LOW  C3  AND LOW  C4 

She has  frothy  urine 

Plan 
Referral to the hospital as her blood  pressre  is  high 
No hematuria 
Creatinine   1.5  in   11/5
Renal ultrasound showed  right kidney 12   eft  kidney 10/8
Echo showed mild   pericardial effusion
Wbc  10  hgb10/7
Esr    58
Crp 31
Ast  10

Creatnine  1.8
Albumnin  3
Proein/creatinine 6  gram 
Ana  positive 
Low c3  and low  c4 



12/12
proeinuria   250/161
creatinine   1.3 
wbc        14  .7    hgb   13.1   plt    272
esr  10 
c3    1.2  normal 
c4   0.21  normal 
albumin 3.5  normal 
alt    13  