16/09/23, 60M with fever, cough, pain in multiple joints
MED CASE :-
This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
CHEIF COMPLAINT:
A 60 year old male came to the OPD with cheif complaints of
-Pain in multiple joints since 2 years
-Cough since 15 days
-Fever since 10 days
HOPI:
patient was apparently asymptomatic 2 yrs back then he had multiple joint pains( both hands metacarpophalangeal joints and both knee joints.joint restriction present . morning stiffness present
c/o lower limb swelling since 1 yr pitting type till ankle
H/o trauma to left leg middle toe 1 month back
H/o cough with sputum
No c/o decreased urine output, burning micturition, headache
H/o chronic NASID abuse since 1 yr for joint pain
PAST HISTORY:
n/k/c/o HTN DM TB epilepsy CAD CVA asthama
FAMILY HISTORY :
Not significant
PERSONAL HISTORY:
Mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements
No known addictions and allergies
GENERAL EXAMINATION :
PT is concious coherent co-operative
Well oriented to time place person
Moderately built and moderately nourished
No pallor, cyanosis,icterus, clubbing of fingers, generalized lymphadenopathy, pedal oedema
VITALS:
he is afebrile
BP: 130/90 mm of hg recorded in right arm in supine position
RR: 18cpm
PR: 68 bpm
LOCAL EXAMINATION:
There is swelling and pain and also restricted movements seen in multiple joints :
Both wrists
Distal phalangeal joints of both hands
Both knees
Both ankles
Both elbows
Left shoulder
no local rise of temperature
Soft and non tender
SYSTEMIC EXAMINATION:
-CVS:S1 S2+,NO MURMURS
-RS:BAE+ ; NVBS ; No added sounds
-P/A: no palpable mass, no tenderness, no organomegaly
-CNS: no focal neurological deficit
-MUSCULOSKELETAL SYSTEM:
Rt. Lt
MCP joints +. +
DIP joint +. +
pIP joint +. +
INVESTIGATIONS:
-chest x-ray:
-ECG:
