A 45 year old female came to the opd with chief complaint of multiple joint pains since 1 week
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June 14th 2021
Paramkusham Sai krupa sri
Roll. No : 175
A case discussion of
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.
CASE PRESENTATION:
A 45 year old female came to the opd with chief complaint of multiple joint pains since 1 week
CHIEF COMPLAINTS: of multiple joint pains since 15 days
Complaint of restriction of movements, difficulty in walking since 1 week and
Difficult in getting up from supine position distal extremities
Complaint of tingling and Numbness at bilateral lower extremities since 1week
HISTORY OF PRESENT ILLNESS:
• Patient was apparently asymptomatic 15 days back then she complained of pain at bilateral knee joint followed by elbow and ankle joint shoulder joint , MCP, IP Joints. she went to outside local hospital used painkillers for 10 days no improvement
• She has history of tingling sensation at bilateral lower limb extremities since 13 days not relieved on medication , Mild swelling at knee joint , no local rise of temperature
•Initially there is difficulty in getting up from supine position and difficulty in mixing food , combing hair
•Later she is able to get up from supine position able to walk able to mix food comb hair , outside she received TAB HCQS 200mgBD , Tab aceclofenac 100mg + thinochloride 4 mg ,tab deflacort 6mg BD
• She has History of neck pains and restriction of lateral neck movements complaints of loss of appetite since 1week
PAST HISTORY:
History of Type 2 Diabetes since 12 years on oral medication started on insulin since 5 years mixtard insulin
No history of hypertension, Asthma, TB epilepsy, CUA, CAD
PERSONAL HISTORY :
Diet : Mixed
Appetite : Normal
Sleep : Adequate
Bowel and bladder : Regular
Micturition : Normal
No addictions
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
She is well oriented to time, place and person.
She is moderately nourished.
Dehydration - present
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Edema
VITALS:
Temperature: Afebrile
Pulse rate - 84bpm
Respiratory rate - 14 cycles / min
Bp: 130/80
SPO2 : 98% at room air
SYSTEMIC EXAMINATION:
Cardiovascular system : S1, S2 is heard. No murmurs are heard.
Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
Per Abdomen : Soft, Non-tender
Central nervous system :
Higher mental functions intact
Cranial nerves intact
Motor system -
Right left
UL - Tone- N N
LL -. Normal. Normal
Reflexes -. Right left
Biceps 2+ -
Triceps 1+ 1+
Spinal 1+ 1+
Knee - 1+
Ankle + +
Plantar Flexor Flexor
Fine touch - negative
Joint sense - negative
Crude touch - positive
Romberg's - negative
INVESTIGATIONS:
Hemogram:
Complete urine examination:
HIV 1/2 Rapid Test :
Anti HCV Antibodies - RAPID:
HBsAg- RAPID :
ECG :
X - ray:
PROVISIONAL DIAGNOSIS:
Known case of Type 2 Diabetes Mellitus , Athralgia (multiple joint pain).
TREATMENT :
1) Inj HAI |sc| TID after informing GRBS
8am ___ 2 pm ___ 8pm
2) Inj optineuron 1 amp in 100ml ns/ IV /OD
3) Inj tramadol 1 amp in 100ml ns /IV/OD
I would like to thank Dr.Rakesh biswas sir for giving me this opportunity and Dr. Sai Charan sir for the guidance.
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