57 yr old male with B/L- LL swelling and multiple joint pains

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🩺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 inputs on the comment. I am Nomika Alli (Roll no 179) of 6th Sem, MBBS.

A 57 year old male farmer by occupation resident of Suryapet came to the opd  on 12-12-22 with

  

CHIEF COMPLAINTS :-

Swelling of bilateral lower limbs and right upper limb since 15 days, pain in multiple joints since 15 days , and difficulty in walking since 3 days.

HISTORY OF PRESENT ILLNESS:-

• Patient was apparently asymptomatic 15 days back then he noticed swelling in bilateral lower limbs and upper limbs which was insidious in onset and gradually progressing extending upto knees.

• He also had complaints of pain since 15 days in multiple joints which was aching, insidious in onset, gradually progressing, non radiating.

•He also had complaints of difficulty in walking since 3 days .

•No complaints of loose stools, vomiting ,burning micturition.

• No complaints of pnd, cough, chest pain, palpitations.

•No complaints of decreased urine output, hematuria.

HISTORY OF PAST ILLNESS:-

He is  not a known case of DM,HTN, Bronchial asthma , Epilepsy , CAV , CAD.

PERSONAL HISTORY:- 

DIET:- Mixed

APPEPITE:- Normal

SLEEP:- Adequate 

BLADDER AND BOWEL MOVEMENTS :- Regular

ADDICTIONS :- Alcohol intake ,no smoking

FAMILY HISTORY:- 

No relevant family history

SURGICAL HISTORY :- 

No past surgical history

GENERAL EXAMINATION:-

Patient is conscious coherent cooperative

Well oriented to time, place, person

Thin built moderately nourished

Pallor- present

Icterus - absent

Pedal edema - present

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent

VITALS:- 

Temperature:- Afebrile (98.6)

Pulse rate :- 100 BPM, regular

Respiratory rate :- 20 cpm

BP:- 130/90

SpO2:- 98%

BEFORE:

NOW:

SYSTEMIC EXAMINATION:-

CARDIOVASCULAR SYSTEM:-

AUSCULATION:-

S1 ,S2 heard 

No murmurs

RESPIRATORY SYSTEM:- 

INSPECTION:-

•Trachea is central in postion.

•Movements are equal bilaterally.

•No scars or sinuses.

PALPATION:- 

•All inspectory findings are confirmed :- Trachea is central, movements equal and bilateral.

PERCUSSION:- 

• Resonant note heard bilaterally

AUSCULATION:-

•Bilateral air entry present- Normal vesicular breath sounds heard.

PER ABDOMEN:- 

•Scaphoid 

•Soft non tender 

•No organomegaly

•Bowel sounds present

•Tympanic note heard all over the abdomen.

CENTRAL NERVOUS SYSTEM:-

•Speech- Normal

•Reflexes - reduced

•No signs of meningeal irritation

•No focal neurological deficit

PROVISIONAL DIAGNOSIS

•?Polyarthralgia

INVESTIGATIONS

ECG:

USG ABDOMEN:-

2D ECHO:-

TREATMENT:-

1.