60 yr male with fever and multiple joint pains
September 15, 2023
Hi, I am P.Durga Bhavani 5th sem 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 this piece of work whatsoever.
Chief Complaint:
60 year old male,resident of chittyala, farmer by occupation came to OPD with chief complaints of
- fever since 10days
-Multiple joint pains since 1 year
History of Present Illness:
-Patient was apparently asymptomatic 1 year back then he had multiple joint pains(both hands metacarpophalanygeal joints ,both knee joints,both elbow joints) since 1 year
-Joint restriction present
-Morning stiffness present
-c/o lower limb swelling since 1 year (pitting type)
- gives h/o trauma to left leg middle toe 1 month back
-c/o weight loss since 6 months
-h/o fever sive 10 days which is high garde and associated with chills and rigors which was more during night and relieved on medication.
-c/o decreased urinary output
-No h/o cough
Daily Routine:
Before he got sick, he used to wake up at 5am every morning, take a bath at 6.30am, eat breakfast of rice and curry and leave for work by 8.30am. He is a daily wage laborer by occupation and he used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. He used to reach home by 7 or 8pm after which he would eat rice and curry, and sleep by 11pm.
After he got sick, he stopped going to work and stayed at home, following which he was admitted into the hospital.
Past History:
h/o chronic NSAIDS abuse since 1 year for joint pains.
Not a k/c/o DM, HTN, CAD, TB, epilepsy.
Personal History:
- married
- decreased appetite since 1 month
- mixed diet
- regular bowels
- normal micturition
- no known allergies
- addictions: smoked 1 pack for 20 years stopped 1 year back
Family History: not significant
Drug History:
NSAID for joint pains
General examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
-mild pallor
- no icterus
- no cyanosis
- clubbing of fingers present
- no lymphadenopathy
- edema of feet:pitting type of edema upto knee
- no malnutrition
- mild dehydration
Vitals:
- Temperature:101 ⁰F
- Pulse: beats/min
- RR: 16 cycles/min
- BP: 120/70mm Hg
-SPO2:90%
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- no wheeze
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination :normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
Hemogram
Urine examination
ECG:
Provisional Diagnosis:
Rheumatoid Arthritis with CKD
