Hi, I am Shivraj Sontakke , 5th semester medical student.
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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I've 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 come up with a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever. This is a case of 50 year old female who presented with multiple joint swelling and pain
Chief complaints :
Multiple. Joint pains and swelling
History of present illness:
Patient was apparantly asymptomatic 5 years ago then she developed swelling in the left knee joint which is insidious in onset gradually progressive it is associated with pain in the knee which was agrravated on walking and doing work and relieved on medication.then she developed pain and swelling at multiple joints .
No history of trauma fever rashes diarrhea jaundice.
History of past illness:
She is not a known case of DM/HTN/TB/ASTHMA
FAMILY HISTORY
There are similar complaints with the mother
PERSONAL HISTORY:
DIET:MIXED
APPETITE :NORMAL
BOWEL AND BLADDER : REGULAR
SHE CONSUMES ALCHOL REGULARLY BUT STOPPED CURRENTLY 5 months ago and she smokes beedi regularly .
GENERAL EXAMINATION;:
Patient is conscious coherent cooperative
Vitals :
BP:
PR:
RR:
Temperature:afebrile
Pallor :present
Icterus :absent
Cyanosis :absent
Clubbing :absent
Lymph adenopathy: absent
Paedal oedema : absent
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 heard no murmurs
Resp:bilateral normal vesicular breath sounds heard
CNS:
No focal neurological deficits
Provisonal diagnosis :
Rheumatoid arthritis
Investigations :
CBP:
impression : normocytic normochromic picture with moderatly anaemic
RBS:
X- ray
PA view of chest
