General medicine case 14-09-23

 GENERAL MEDICINE CASE (14-09-23)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 11/09/23


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 there is an diurnal variation , stiffness is seen on early morning on waking up which gradually decreased by the end of the day .
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:128/76 mm hg
PR:78 bpm
RR: 14 cpm
Temperature:afebrile

Pallor :present 

Icterus :absent 
AA ab da svsdsbddbddddbsdsddvsbsscs DD dbddvqaf DD adqCyanosis :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:
ESR:


Rheumathoid factor: 


X- ray
PA view of chest



Some other clinical images of patient :

ECG report :


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