50 Y/F COME C/O PAIN IN BOTH KNEES SINCE 1 MONTH

This is an a online e log book to discuss our patient 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 centered 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 plan
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

C/O PAIN IN BOTH KNEES SINCE 1 MONTH

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK , THEN SHE DEVELOPED PAIN IN BOTH KNEES INSIDIOUS ONSET, PROGRESSIVE IN NATURE AND INABILITY TO SQUAT.

NO H/O TRAUMA, FEVER, COLD, COUGH.

NO H/O CHEST PAIN, PALPITATIONS, ABDOMINAL PAIN.TFT:

T3- 0.86

T4-11.96

TSH-10.68

NO H/O BURNING MICTURITION, LOOSE STOOLS, CONSTIPATION.

NO H/O WEIGHT GAIN, HEAT/COLD INTOLERANCE.

NO H/OPEDAL EDEMA, FACIAL PUFFINESS.

PAST H/O:

K/C/O HTN SINCE 3 YRS AND ON TAB. TELMA 20 MG PO OD

K/C/O HYPOTHYROIDISM SINCE 1 YR ANDON T. THYRONORM 125MCG

NOT A K/C/O D, TB, ASTHMA , CAD, CVA, EPILEPSY .

GENERAL EXAMNATION :

PATIENT IS C/C/C

TEMP-AFEBRILE

PR-76 BPM

RR-16CPM

BP-120/70 MMHG

SPO2- 98 % AT RA

GRBS- 100 MG/DL

SYSTEMIC EXAMINATION

CVS - S1,S2 HEARD

RS - BAE PRESENT, NVBS +

CNS - NFND

P/A - SOFT, NON TENDER, BOWEL SOUNDS HEARD

INVESTIGATIONS:

HEMOGRAM:

HB-13.0 GM/DL

TLC- 12,400

PLATELETS-2.32

HBA1C- 7.1%

FBS: 316 MG/DL

PLBS: 336 MG/DL

COMPLETE URINE EXAMINATION (CUE) 25-01-2024 04:26:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR ++++

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

Anti HCV Antibodies - RAPID 25-01-2024 04:26:PM Non Reactive

HBsAg-RAPID 25-01-2024 04:26:PM Negative

RFT 25-01-2024 04:26:PM

UREA 16 mg/dl 42-12 mg/dl

CREATININE 0.8 mg/dl 1.1-0.6 mg/dl

URIC ACID 2.9 mg/dl 6-2.6 mg/dl

CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.9 mg/dl 4.5-2.5 mg/dl

SODIUM 137 mEq/L 145-136 mEq/L

POTASSIUM 4.1 mEq/L 5.1-3.5 mEq/L

CHLORIDE 98 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 25-01-2024 04:26:PM

Total Bilurubin 0.73 mg/dl 1-0 mg/dl

Direct Bilurubin 0.14 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 21 IU/L 31-0 IU/L

SGPT(ALT) 28 IU/L 34-0 IU/L

ALKALINE PHOSPHATE 187 IU/L 98-42 IU/L

TOTAL PROTEINS 7.2 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.0 gm/dl 5.2-3.5 gm/dl

A/G RATIO 1.26

TFT:

T3- 0.86

T4-11.96

TSH-10.68




TREATMENT :

TAB. NAPROXEN 250 MG PO/ BD 1--0--1

TAB. TELMA 20 MG PO/ OD 1--0--0

TAB. GLIMI -M1 PO/ OD 1--0--0

TAB. THYRONORM 125 MCG PO/ OD 1--0--0

TAB. PAN 40 MG PO/OD 1--0--0


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