65 year old female with ??osteoarthritis

This is 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 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

Name: M.Srilekha (intern),roll.no:88

Chief complaints:

Complaints of joint pains since 4 years With tingling sensation of upper and lower limbs 

Unilateral right sided head had since 2 years  

history of presenting illness:

Pt was apparently asymptotic 4 years back then she developed joint pains first lower limb joints are I nvolved then upper limb joints involved gradually (elbow joint,shoulder joint, interphalangeal joints) more on right side

Restriction of movements present 

Morning stiffness present

No local rise of temperature 

No localised swellings on joints 

Tingling sensation in both upper and lower limbs more in right side 

No numbness loss of sensations

Unilateral headache right sided,photophobia present phonophobia present

No vomitings

Pitting type of deal edema preset

No decreased urine output

No h/o fever , cough, sob 

Past history:

Known case of hypertension since 4 years on Tab.AMLOG 5 mg OD

Known case of diabetes mellitus since 9 months on Tab.GLIMIPRRIDE Tab.METFORMIN

Surgical history: hysterectomised 20 years back 

Personal history:

Diet mixed

Appetite normal

Bowel and bladder regular

Sleep adequate 

No known allergies 

Family history:not significant

General examination:

 Pt is conscious coherent cooperative 

Pitting edema present below knees

No pallor icterus cyanosis clubbing lymphadenopathy 

Vitals:

afebrile,89 bpm,130/90 mmHg,19 cpm,spo2-98%

CVS: S1S2 heard no additional sounds heard

RS: trachea central in position 

BAE+, NVBS +

CNS: 

Spinothalamic     Rt       Lt 

Crude touch UL  N         N

                     LL  N         N

Pain              UL N         N

                     LL N          N

Temperature UL N         N

                     LL N         N

Posterior column  Rt        Lt

Fine touch    UL  N        N

                       LL   N       N

Vibration        UL  7sec      6sec

                              7sec       5sec

                       LL   4 sec.    4 sec      

                               5sec      6sec

Position sense  UL  7/10     7/10

                         LL   6/10    8/10

Romberg's test negative 

Cortical                  UL     LL

Tactile localisation N       N

Investigations:

USG abdomen: impression: grade 2 fatty liver

ECG:

X-rays 

X-ray lateral and AP view bilateral knee

2D echo:

Trivial TR/AR no MR

No RWMA no AS/MS sclerotic AV

Good LV systolic function

Diastolic dysfunction present no PAH,PE

Provisional diagnosis: osteoarthritis with hypertension and type 2 diabetes mellitus

Treatment:

Tab.ULTRACET po/qid