A 60year old female with joint pain ,edema and swelling of face

July 21,2023

Hi,I am Athram Divya Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 

                      CASE SHEET

CHIEF COMPLAINTS:

A60 yr old female resident of miryalaguda labour by occupation came to OPD with chief complaints of

Bilateral joint pain since 4 to 5 yrs

Facial swelling since 2 to 3 months

Pedal edema since 1week

HOPI:

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 month ago, she had a tooth extraction on the left side and still has facial puffiness on the left side.

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 disappeare

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:-

USG:

PROVISIONAL DIAGNOSIS:-

Facial puffiness under evaluation

TREATMENT:-

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

Aspirin

Rosuvastatin

Furosemide