THESIS MODEL 7 CAMP

 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 55yrs old male, resident of  chandhupatla , house wife  by occupation came to camp screening with chief complaints of  pain in the right knees since 5years and limitation of movements of both upper limbs since 1year

History of presenting illness :
Patient was apparently asymptomatic 5years back then he developed pain in the both kness insidious in onset progressing in intensity to a stage where she is unable to get up from cot ,unable get up from sitting position and unable to sit down  difficulty in climbing slopes 
she also complaints of unable to lift the hand above the shoulder of both upper limbs  since 1 year this restriction of movements is gradually progressed fom limitation of 90 to 30 degrees gradually
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  medication telma-h once daily and dm-2 since 5 year on  medication glimi m1 daily in the morning and metformin 500 in the evening 
N/K/C/O,  Asthma, TB,CAD,CVA

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
 pedal edema ABSENT 

Vitals:
Temperature : 98.6F
Pulse rate: 87bpm
Respiratory rate: 22cpm
BP: 140/90 mm Hg
SpO2: 99
GRBS:215mg/dl

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 e in both knees 
swelling present in both knees 
patellar tap negative in both knees 



106 CMS




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