GM case 1

GM case 1
Case scenario.....
Hi, this is k.vaishnavi , IIIrd BDS. This is an online eblog book discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

 CASESHEET:a 65 year old women with joint pain and tingling.


Chief complaints: joint pain and tingling sensation since 10 days .

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic before 4 years .
Since 4 years the patient is suffering from joint pain. The pain has became sever since patient has fallen from stairs before 10 days .
The patient has developed joint pain first in lower limb and the to upper limb involving elbow and shoulder joint .
Swelling at joints are seen.
The tingling sensation of upper and lower limb.
Right side headache since 2 years.
Associated diseases:
Type II diabetes mellitus 
Hypertension 
 
History of past illness:
Type II diabetes mellitus since 1year and on medication of 
METFORMIN HYDROCHLORIDE 100 mg
GLIMEPIRIDE 1mg
And 
Hypertension since 3 years and on medication of
AMLODIPINE 5 mg. 
PERSONAL HISTORY: 
Appetite : Normal 
Diet: Mixed 
Bowel and bladder movements: Regular 
Addictions : Nil
Micturition: normal
Known Allergies : nil

FAMILY HISTORY: 
Not significant 

GENERAL EXAMINATION:
Pallor : no
Icterus :no
Cyanosis : no
Clubbing : no
Lymphadenopathy : no
Edema : no

VITALS:
Temperature: 98.6°c/f
Pulse: 69beats per minute
Respiratory rate: 16cycles per minute
Blood pressure: 130/90 mm of Hg
SPO2: 98%

SYSTEMIC EXAMINATION:

Upper respiratory tract examination:
Left sided deviated nasal septum 
Oral cavity- normal oral hygiene 
Lower respiratory tract :
Inspection :
- shape of chest is symmetrical,elliptical 
- Chest expansion equal on both sides 

Palpation :

All inspectory findings are confirmed with palpation.
 Trachea central in position.
 No local rise in temperature
 No tenderness 
 Chest movements: Equal on both side.

  Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No

PROVISIONAL DIAGNOSIS:
Osteoarthritis.

Questions from patient :
1. How long does take to cure?

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