Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve 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 and come up with diagnosis and treatment.
Case sheet:
Chief Complaints:
A 82yrs old male, resident of chandhupatla , farmer by occupation came to camp screening with chief complaints of pain in the both knees since 6years
History of presenting illness :
Patient was apparently asymptomatic years back then he developed pain in the both kness insidious in onset progressing in intensity to a stage where he is unable to get up from sitting position and unable to sit down
no h/o trauma
no h/o fever chills cold cough
no h/o abdominal pain
Past history:
Patient is a known case of hypertension since 5years on unknown medication and dm-2 since 8 year on unknown medication
N/K/C/O, Asthma, TB,CAD
allergic history : Not significant
Drug history: not significant
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements : regular
Addiction : occasional alcohilic, non smoking
Family history: Insignificant
General examination :
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema
Vitals:
Temperature : 98.6F
Pulse rate: 88bpm
Respiratory rate: 20cpm
BP: 130/80 mm Hg
SpO2: 98
Systemic examination :
Respiratory system :
Vesicular breath sounds heard
No additional breath sounds heard
Cardiovascular system :
S1 S2 heard
No murmurs
Abdomen:
Soft, non tender
OBESE
CNS:
No neurological deficits seen
JOINT EXAMINATION:
Local raise of temperature positive in both knees
crepitus positive in both knees
swelling absent in both kness
patellar tap negative in both kness

100CMS

34CMS

36CMS