60 yrs old male with bilateral wrist joint pain and left first MTP joint pain since 3 months.

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.

 B.Pavithra(Intern)

Roll no:9

Presenting complaints:

1.bilateral wrist joint pain since 3months.

2.left 1st MTP joint pain since 3 months.

HOPI:

Patient was apparently assymptomatic 3 months back and then he developed bilateral wrist joint pains(right>left) which is insidious in onset gradually progressive,pricking type of pain associated with right wrist swelling.

C/o bilateral ankle joint pains and left 1st MTP joint pain which is insidious in onset gradually progressive,pricking type of pain associated with bilateral ankle swelling,aggrevates on walking ,relived partially on medication.

C/o  right 1st MCP joint pain since 2 months

No complaints of pain in other joints like knee,shoulder,elbow and other small joints.

No c/o back pain and neck pain.

No h/o trauma.h/o trauma to right little finger got amputated during trauma.

No h/o fever,vomiting,nausea and headache.

No h/o sob,paipitaions and cough.

No h/o burning micturation, terminal dribbling,decreased or increased urine output.

H/o nocturia(wakes 4 times in the night)

PAST HISTORY:

K/c/o hypothyroidism since 3 yrs on thyronorm(37.5mcg)

NO h/o DM,HTN,TB,asthma,epilepsy,CVA,CAD 

NO H/O previous surgeries and blood transfusions. 

PERSONAL HISTORY:

DIET:mixed

APETITE:normal

SLEEP:adequete 

BOWEL:regular

BLADDER:nocturia (4 times)

ADDICTIONS:smoker for 35 yrs smokes 5 beedis per days stopped 3 yrs back.

Drinks alcohol occasionally since 30 yrs.

FAMILY HISTORY:H/O dm type 2 and htn to his mother and his elder brother.

TREATMENT HISTORY:

no drug allergies 

H/o swelling and pains of wrists and ankle joints after taking meat.

GENERAL EXAMINATION:

Patient is conscious,  coherent and cooperative, moderately build and moderatly nourished. 

No signs of pallor,icterus, cyanosis,clubbing,generalised lymphadenopathy and bilateral pedal edema.

Vitals:

Temp:afebrile

BP:130/80

RR:17cpm

PR:76 bpm

SPO2: 100% ra

Examination of joints:

On/I: mild swelling present in right wrist joint and restricted movements around the right wrist.left wrist is normal

No redness and scars and discharge. 

On/P:No local raise of temperature. 

Joint line tenderness present in the right wrist and mild tenderness present in left wrist.

Joint line tenderness present in both the ankles and left 1ST MTP JOINT.

SYSTEMIC EXAMINATION:

Rs: 

Shape of the chest is normal moving symmetrically with the respiration. 

Bilateral air entry present

Normal vesicular breath sounds are present.

CVS:

Apex beat is localised in lt 5th ics 2cm lateral to lid clavicular line

S1 and s2 are heard

No murmurs 

CNS:

                    Rt             lt

Biceps.     2+               2+

Triceps.     1+             1+

Supinator  not able to do           1+

Knee.         2+           2+

Ankle.       1+              1+

Tone:          normal         normal

Power:        UL       LL

        RT        5/5     5/5

        LT       5/5         4/5

SENSORY EXAMINATION;

Spinothalamic:     rt     lt

Crude touch          N        N

Pain                       N         N

Temperature     perceives

Dorsal coloumn:

Fine touch            N           N

Joint proprioception:   9/10     9/10

PER ABDOMEN:

Shape: obese,umbilicus is inverted,centrally located 

No engorged veins and visibles scars and sinus.

SOFT. NON TENDER.

NO ORGANOMEGALY

INVESTIGATIONS:

ECG:

2D -ECHO:

Ultrasound-abdomen:

X-rays:

TREATMENT:

TAB.PAN 40 MG PO/OD

TAB.ULTRACET PO/BD

TAB.NEUROKIND-LC PO/BD

TAB.ACECLO P PO/BD

TAB.TYROXINE 37.5 MCG

TAB.PREGABALIN 75 mg po/od