A 60 year old female with joint pains

July 19, 2023

 Welcome to my blog! I am Nidhi , a 3rd year  medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below. 

I have been given this case 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, diagnosis and treatment plan.

CASE:-

A 60 year old female, who was an agricultural labourer by occupation (but has stopped working since 4 years), came to the hospital with complaints of  pain in both knees since 4-5 years, facial swelling since 2-3 months, pedal edema since 1 week.

HISTORY OF PRESENTING ILLNESS:-

The patient was apparently asymptomatic 4-5 years ago. She then started developing pain in both her knees which is aggravated on walking and standing, relieved on resting and medications (painkillers). She stopped working due to the pains.

2-3 months ago, she developed facial puffiness which was insidious in onset and gradually progressive in nature. It appears maximally in the mornings and gets relieved by the end of the day. 

1 week ago, she had pedal edema upto her ankles which was pitting in nature. This also appears maximally in the morning and subsides by the end of the day. Her edema greatly subsided by itself after a week.

She came to the hospital now to find a working solution for her joint pains and to find out about why her pedal edema appeared and disappeared.

DAILY ROUTINE:-

The patient wakes up in the morning at 5:30 and begins household chores, eats breakfast at 8:00. She smokes tobacco at this time.

She then passes her time by talking with family members or guests till 11:00, when she cooks her lunch and eats lunch late, around 3:00-4:00pm

She has tea occasionally in between, when she visits family. She spends time sleeping or talking with friends and family in person or on the phone.

At night, she doesn't feel hungry. She may or may not smoke tobacco again. She then sleeps at around 10:00pm.

This has been her routine since 4 years, after she stopped working.

PAST HISTORY:-

Not a known case of diabetes, hypertension, CVA, CAD, TB, asthma

FAMILY HISTORY:-

Not significant.

TREATMENT HISTORY:-

The patient has a history of using NSAIDS 3-4 days a week since 4 years for the joint pains, suggested by and RMP.

PERSONAL HISTORY:-

Appetite: normal

Diet: mixed

Sleep: adequate

Bowel movements: regular

Micturition: normal

No known allergies

Addictions: Smokes tobacco once or twice a day everyday

MENSTRUAL HISTORY:-

Attained menopause 20 years ago

OBSTETRIC HISTORY:-

Age at marriage: 18 yrs

Age at first childbirth: 20

Obstetric formula: G5P5L5

All normal vaginal deliveries

GENERAL EXAMINATION:-

The patient is conscious, coherent, cooperative and well-oriented to time, place and person.

The patient is moderately built and well-nourished.

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy

Pedal edema present in right foot (grade 1)

Vitals:-

Temperature: Afebrile

Blood pressure: 120/80mm Hg

Pulse rate: 82 bpm

Respiratory rate: 18cpm

SYSTEMIC EXAMINATION:-

CNS: Patient is conscious, coherent and cooperative, well-oriented to time, place and person

CVS: S1, S2 sounds heard, no murmurs

Respiratory system: trachea central, normal vesicular breath sounds heard, no added sounds

Abdomen: distended, no palpable organs.

INVESTIGATIONS:-

19.07.2023:-

Ultrasound:-

ECG:-

PROVISIONAL DIAGNOSIS:-

Facial puffiness under evaluation

TREATMENT:-

Took Potassium citrate and magnesium citrate for pedal edema, given at government hospital.

Aspirin

Rosuvastatin

Furosemide