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%

https://drive.google.com/uc?export=view&id=1-O7OV5ay-KM71ipA5hqKyWf7Rl2N3rGQhttps://drive.google.com/uc?export=view&id=1KgIOPuy2SNmu-OfSh-yS89ZDN8_3udszhttps://drive.google.com/uc?export=view&id=1vfgFHNiKeOy_qY7tsf6zXllnpA94BrMc
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:https://drive.google.com/uc?export=view&id=1edrQ7n9XWdTQKPFQHHwuJchp7FBKIEP9
https://drive.google.com/uc?export=view&id=1wemhnRpO62HO2Owkwn0GkOgWWtHfVxZz

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