A 33yr old male with head ache and stiffness of joints
July 20,2023
Hi,I am Nidhi 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 33yr old male patient labour by occupation came to OPD with chief complaints of headache(on and off) since 1yr and stiffness of joints.
HOPI:
-Patient of apparently asymptomatic 1yr back then he developed headache of unilateral side(Right) with full aching pain
-also had complaints of joint stiffness on sitting for a long time.
Negative history: no photophobia, no watering of eyes,no blurring of vision,no vomitings.
No restrictions of movement,no difficulty in standing,no fever,no abd pain,no SOB, no cough and cold
PAST HISTORY:
Not known case of hypertension,DM,CAD,TB,epilepsy
PERSONAL HISTORY:
married
Appetite:normal
Diet:mixed
Bowel: normal
Micturition:normal
No known allergies
No addictions
FAMILY HISTORY:
not significant
GENERAL EXAMINATION:
No pallor,icterus,clubbing of fingers,cyanosis,lymadenopathy
Vitals:
Temperature:afebrile
Pulse rate:90/min
Respiratory rate:16/min
BP:120/80mmhg
Spo2:98%
Systemic Examination
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
no dyspnea
No wheezing
central trachea
vesicular breath sounds
Abdomen
Obese shaped abdomen
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
Investigations:
ECG:
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