General medicine 8

GM- CASE


CASE scenario....

Hi, I am k.sahalya, 3rd year bds student. This is an online elog book to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.

CASE HISTORY : A 45 year old known case of joint pains 
CHIEF COMPLAINTS : joint pains (wrist,ankle,neck back) from 4 years

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic  4 years ago,then joint pain started ,it is at wrist,ankle,neck back, tingling like sensation, at ankle it is non radiating, at wrist it is non radiating and at neck back it is radiating bilaterally to shoulder, their is no progression in pain , aggravates on doing work and during morning ,releaved on medication 

PAST ILLNESS :
Known case hypertension from 20 years on medication  Not a know case of diabetes,
Known case of renal failure

PERSONAL HISTORY : 
Mixed diet, appetite is normal, have proper sleep, regular bowel, drinks toddy ,stopped 4 years back.

FAMILY HISTORY : 
No relavent history 
GENERAL EXAMNLINATION : 
Built : moderately built
Nourishment : moderately nourished
Consciousness: in Conscious
Pallor : no 
Icterus : no 
Cyanosis : no cyanosis 
Clubbing : no clubbing 
Lymphadinopathy : no lymphadenopathy 
Edema :no edema 
 Systemic examination:
Wrist: inspection; no radial deviation of wrist ,no diffuse edema , no redness.
Palpation ; temperature  increased 
Range of movement; limited and painful active movements of flexion and extension 
Ankle: pain and limitation of movements of flexion 
Diagnosis: osteoporosis 

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