33 year old male with headache & stiffness of joints

33 year old male with headache & joint stiffness

July 20, 2023

This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s 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 patients 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 comments box is welcome

Chief complaints
On and off headache since 1 year
Stiffness of joints on prolonged sitting
History of Present Illness
Headache
Patient was apparently asymptomatic 1 year back then developed headache of u/l right side associated with dull aching pain
No Photophobia
No Phonophobia
No Watering of eyes
No Blurring of vision
No Vomitings

Stiffness of joints
No restriction of movements
No Difficulty in standing from sitting position
No Fever, Abdominal pain,cough,cold, diarrhoea 
History of Past Illness
Not a k/c/o HTN,DM,Asthma,TB,CAD, Epilepsy 
Treatment history
Not significant
Personal history
Married 
Daily labour, fisherman
Normal appetite
Mixed diet
Regular bladder & bowel movements
No known allergies
Addictions - Nil
Family history
Not significant 
General examination 
Patient was conscious, coherent, cooperative 
No signs of pallor, icterus, cyanosis, clubbing, Lymphadenopathy and pedal edema 
Vitals
Temperature - Afebrile
Pulse Rate-90/min
Respiratory Rate-16/min
Blood Pressure -120/80 mm Hg
SPO2- 98%

SYSTEMIC EXAMINATION
Cardiovascular System
Thrills- no
Cardiac sounds- S1, S2 +
Cardiac murmurs - No

RESPIRATORY SYSTEM
Position of trachea- central
Breath sounds- vesicular
No Dyspnea and wheezing 
Absomen-obese
No tenderness
No palpable mass
Normal hernial orrifices
No bruits, free fluid
Liver,spleen- not palpable
Bowel sounds- yes
Central Nervous System
Conscious
Normal speech 
No neck stiffness

Investigations
Random Blood Sugar 
Blood Urea
Serum Creatinine
Serum Electrolytes
ECG
2D Echo



























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