30 year male with multiple joint and muscle pains from past 4 years worsening since 6months.

January 27, 2021

Unit 3:

Interns:

Dr Archana

Dr Sreeja

Dr Harsha

Dr Kalyan

Dr Sahithi

Dr Jeehariki

Dr Raveen PGY1

Dr Aashitha PGY2

Dr Aravind PGY3

Dr Vamshi PGY3

Dr Hareen SR

Dr Praveen Naik Ass Prof

DR. RAKESH BISWAS HOD

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:

Admission under unit 3 on 27/01/2021

30 years young man is a farmer by occupation and is a part time stone driller presented with pain in multiple joints and muscles from past 1 year, which is worsening since six months.

HOPI: Patient was apparently a symptomatic 4years back. His previous recall of events dates back to four years where he noted swelling and tenderness of PIP And MCP of both hands - early in the morning, subsiding in the evening without any medication. He used to take medication on and off But not for the swelling and the joint pains as they would subside.

Recent history: His symptoms started worsening from the past six months starting from the bilateral knee pain followed by PIP and MCP joints and wrist joint. He denies the history of elbow joint/ankle joint/DIP joint involvement. He gives a history of fever preceding the joint pain. He points out vaguely that his symptoms aggravated after sexual activity.

Medical history: known case of hypertension since ?6 months and was on irregular medication.

Not a known case of DM/Asthma/TB/Epilepsy.

Surgical history: He underwent lithotripsy in 2015 for right renal stone of 12 mm size of lower pole calyx. On 2016, he underwent appendectomy in kamineni.

Personal history: Happily married for seven years and are trying for children since then and was found out to be having oligospermia and was on medication and has been unsuccessful.

History of alcohol intake, stopped 5 to 6 years back.

He gives history of multiple joint pains and muscle pains that is (Achilles tendon hamstrings, forearm muscles etc)and hopes to find relief.

On examination :

Patient is conscious, coherent, cooperative. He is well oriented to time, place, person and himself.

He is moderated build and nourished.

BP : 130/90 mmhg

PR: 86bpm, regular rhythm, normal volume.

RR: 18cpm, abdomino-thoracic type of respiration.

Afebrile to touch.