82 year old female with fever and knee jiont pains

 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 patients clinical problems with collective current based inputs.


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.



Patient is a  82 year old female ,housewife,resident of Bidar, came to the casualty with complaints of : 

Cheif complaints:

•Knee joint pain on both legs since 2 days

•Fever since 2 days

History of presenting illness:

Patient was aymptomatic 20 days back. Then she developed knee pain on both sides associated with fever for which she was admitted in  hospital and discharged and diagnosed with Iron deficiency anemia.Since 6 days she had fever which relieved on medication and replases back.


History of past illness

K/C/O Hypertensive since 10 years.

On medication-TELMISARTAN 40mg

(Used AMOXICLAV and DIETHYL CARBAMAZENE for 2 weeks)

N/C/K of Diabetes, epilepsy, tuberculosis cardiovascular disease


Personal History

Married

House wifet

Diet:Vegetarian

Appetite: Reduced

Bowel bladder moments: regular

Addictions : No

Family history:

No other family member had similar complaints 

Menstrual history 

Menopause- 35 years age

On examination

Pt is conscious,coherent and cooperative well oriented to time,place,person 


 Pallor-Mild grade




No signs of  icterus,clubbing,cyanosis,lymphadenopathy ,pedal oedema

Vitals

Temp:102°F

PR: 110

Rr: 24/ min

Bp:120/70 mm Hg. 

Spo2: 94%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 

Resp: Bilateral vesicular breath sound+

         Inspiratory Crepts on both sides

CNS :NAD 

Investigations










Provisional diagnosis: 

Pyrexia , septic arthritis, Iron deficiency anemia



Treatment History 

IV Fluids Normal Saline 50ml/hr

Inj.NEOMAL 1gm IV stat

Tab.DOLO 650 mg TID

Tab.TELMA AM 40/5 mg

Tab. OROFER xt


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