58 years male with multiple joint pains
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I've 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 a diagnosis and treatment plan.
K.Vyshnavi
Roll No - 70
PATIENT CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF :
C/O MULTIPLE JOINT PAIN since 1 month
C/O SCROTAL SWELLING Since 2 months
C/O SCROTAL PAIN since 10 days
Patient was apparently alright 1 month back then he had multiple joint pains both small and large joints sudden in onset, restriction of movement present, tenderness present. No Morning stiffness. No aggrevating factors but relieved by taking medication. He is able to do his routine works but associated with pain.He also complaints of intermittent fever, sudden in onset after any strenous work associated with chills and rigor but relieved by taking medication.Joint pains doesn't increase with fever episodes
Complaint of scrotal pain since 10days which is dragging type of pain, intermittent.No h/o difficulty in micturition or burning micturition
Not a k/c/o DM,HTN,TB, Epilepsy, Asthma
PERSONAL HISTORY :
Appetite -Normal
Diet - Mixed
Sleep - adequate
Bowel and bladder movements -Regular
Addictions: He was occasional alcoholic but now stopped intake
Allergies : No allergies
GENERAL EXAMINATION:
Patient is conscious ,coherent , cooperative, thinly Built and Moderately Nourished .
He was examined under well lit room with consent taken
Temp: 98.4F
BP : 110/80 mmHg
PR : 84bpm
RR : 20cpm
Pallor : absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
CVS : S1 S2 + ,no murmurs
RS : Bilateral air entry present, normal air entry present
P/A : Soft and Non tender
CNS: NFD
INVESTIGATIONS
8/01/23
HEMOGRAM
Hemoglobin: 13.7
TLC: 8,900
[N/L/E/M/B (%)- 68/20/02/10/00]
Platelet: 3.22
MCV: 89.3
MCH: 30.0
PCV: 40.8
RBC COUNT: 4.57
ELECTROLYTES
Na: 145
Cl: 101
K: 4.4
Ca: 9.6
Ph:4.9
RBS-82
RENAL FUNCTION TESTS
Urea: 20
Creatinine: 0.8
Uric acid:5.2
LIVER FUNCTION TESTS
Total Bilirubin: 0.84
Direct Bilirubin: 0.19
SGOT(AST): 17
SGPT(ALT): 10
ALP: 196
Total Protein: 6.8
Albumin: 3.94
A/G: 1.38
Serology - Negative
ESR- 62
CRP - POSITIVE (1.2mg/dl)
RA FACTOR- NEGATIVE
Treatment
T.Prednisolone 10mg po od
T.Methotrexate 7.5mg po od weekly once
T.Folic acid 5 mg po od weekly once after one day of methotrexate intake
Tab.Naproxen 250mg po bd
Tab pcm 650mg po sos
Tab pan 40mg po od bbf
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