52 year old female with chief complaints of Headache Pain over DIP elbow and shoulder joint since 1 month


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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.


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 come up with diagnosis and treatment plan   


Chief complaints-

C/o Headache  since I month

Co Pain over the DIP joint

elbow joint and shoulder joint

since lmonth

2. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 

1 month back, then developed headache

associated with Neckpain, radiating to B/L upper limbs.

Aggrevated with bending forward, relleved with medication clo Pain over the DIP, elbow joint and shoulder joint

-since Imonth, B/L symmetrical in distibution, with morning stiffness lasting for around 5-10 mins,

- No C/o sOB /palpitations (chest pain )

orthopnea

- No c/o Fever decreased urinary output| PND

burning micturition.


3. HISTORY OF PAST ILLNESS

Not a klo HTN, DM2 , thyroid disorders

Bronchial Asthma, CVA, CAD ,TB

Allergic history:-

No history of any kind of allergies to food/drugs


Family history:- 

No significant family history 


GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY




TEMPERATURE:- 98.8 F 

PR:81bpm

BP:120/70 mmHg

RR:17cpm


o/E: of B/L hand:

B/L symmetrical DIP Joints

Pain present over it.

No tenderness 

Synovial thickening-

No external deformity




SYSTEMATIC EXAMINATIONS:-


CVS:S1 S2+,NO MURMURS

CNS: NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 



PROVISIONAL DIAGNOSIS:- 


? Cervical spondylosis ? Rheumatoid Arthritis 


Investigations 

Hemogram 12/9/23 

Hb- 10.4 

TLC - 7200 

Plt count - 2.64 

Pcv - 32.1 

Mcv - 83.8 

Mch - 27.2 

Mchc- 32.4 


UREA 28 

CREATININE 0.9

Sodium - 143

Potassium- 3.7

Chloride -103

CUE - albumin- nil  sugar- nil bile salts- nil 


RBS - 94

X RAY CERVICAL SPINE LATERAL AND AP VIEW 


 

X-RAY KNEE AP AND LATERAL VIEW 


 

 

Treatment

1. HIFENAC-P PO/HS 

2 .TAB . MVT PO/OD

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