A 49 year old female patient with complaints of joint pains and morning stiffness

Hi, we are Geetika Malladi and Faizal of 3rd semester. This an online E logbook to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.

CHIEF COMPLAINT:-

A 49 year old female patient who is a farmer by occupation residing in West Bengal came to the OPD with chief complaint of Joint pains and morning stiffness.

HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 10 years back, then she started having joint pains.The patient had complained of swellings in the upper and lower limb associated with the joint pain. The patient had visited a hospital in West Bengal where she was found to be anaemic .

The patient had also complained of headache associated with the joint pain and fever which seemed to be on and off. A hot climate outside seemed to aggravate her headache and fever. The patient also complained of Vomiting . The patient said that the joint pains , fever and headache reduced after vomiting.

PAST HISTORY:-

No history of diabetes , hypertension, epilepsy ,CAD , tuberculosis and asthma.

DRUG HISTORY:-

FAMILY HISTORY:-

No significant family history of present illness

PERSONAL HISTORY:-

The patient takes a vegetarian diet . Sleep cycle is irregular . Loss of appetite . Urination is 15 times per day . Frequency of bowel movements is once every 2-3 days. Menstrual cycle occurs regularly but only lasts for two days. No history of any addiction.

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative.

BP-120/80mm Hg

PR-78/min

pallor ++, no cyanosis,no lymphadenopathy,no edema