34 yr old male with multiple joint pains since 3 yrs

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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. is an 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. At based input. 

A 34 yr old male resident of west bengal Auto driver by occupation came to opd with chief complaints of

pain in heel since 3 yrs 

pain in neck , b/l knee , wrist , elbow since 3 yrs 

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 3 yrs ago then developed pain in both the heels, which was dull aching type and gradually pain progressed to bilateral knee , hip then to shoulders and followed to elbow , wrist and digital joints. 

Mild Swelling of interphalangeal joints is seen 

Pain increased since 4 months and is more in the morning . 

No h/o tingling sensation , numbness .

No h/o nausea , vomiting , diarrhea , fever 

Past History : 

N/K/C/O Diabetes mellitus , Hypertension, TB , Thyroid disorder , CVA , epilepsy .

H/O cholecystectomy 8 months back 

H/O usage of medication Prednisolone 5 mg and Etoricoxib 90mg since 5 months 

Personal history : 

Appetite - normal

Sleep - Adequate 

Bowel and bladder movements - regular 

Addictions - 

Family history : Not Significant 

General examination 

Patient is conscious , coherent, co-operative , well oriented to time place and person 

Moderately built and nourished 

No signs of pallor ,icterus , cyanosis , clubbing , edema , lymphadenopathy

Vitals 

Temp : 97.8 F

Bp : 110/80 mm hg

PR: 82bpm

RR : 18cpm

SpO2 : 98

Systemic examination 

RESPIRATORY SYSTEM : 

On Inspection 

-Shape of the chest - elliptical ,

bilaterally symmetrical 

- Trachea Central 

- No retractions 

- Movements of chest are equal on both sides 

- No visible scars , sinuses , engorged veins and pulsations 

On Palpation

Inspectory findings are confirmed 

No local rise of temperature

No tenderness 

Trachea center

Ap diameter - 16 cm 

Transverse diameter -23 cm 

Tactile vocal fremitus 

Areas.                  Right.           Left 

Supraclavicular   present.  Present

Infraclavicular    present.     Present

Mammary             present.    present 

Inframammary    present.    Present 

 Axillary             present.         Present

Infra axillary      present.        Present 

Suprascapular     present.      Present 

Infrascapular     present.        Present 

Interscapular     present.       Present 

On Percussion 

Areas.                       Right.       Left

Supraclavicular.      Resonant.    Resonant

Infraclavicular.         Resonant.    Resonant

Mammary.              Resonant     Resonant

Inframammary.        Resonant Resonant

Axillary.              Resonant.        Resonant

Infra axillary.         Resonant  Resonant

Suprascapular.         Resonant.  Resonant

Infrascapular.          Resonant Resonant

Interscapular.           Resonant Resonant 

On auscultation

-Bilateral air entry present 

-Normal vesicular breath sounds heard on all areas  

- No crepts 

- No Rhonchi

CARDIOVASCULAR SYSTEM : 

On Inspection

Shape of the chest elliptical 

No raised Jvp 

Apical impulse - not seen 

Precordial bulge not seen 

No visible sinuses , scars , engorged veins , pulsations 

On Palpation

Apex beat felt at left 5th intercostal space in mid clavicular line 

No thrills and parasternal haeves 

On Auscultation

S1 , S2 heard and no murmurs 

PER ABDOMEN

On Inspection

- Umbilicus is central and inverted 

- All quadrants are moving with respiration symmetrically 

- No visible scars , sinuses , engorged veins and pulsations 

- No hernial orifices 

- External genitilia normal 

On Palpation 

- No local rise of temperature and tenderness 

- Abdomen is soft and non tender 

- No organomegaly 

On Percussion 

- Tympanic note heard over the abdomen 

On Auscultation

-Bowel sounds are heard 

-No bruit

CENTRAL NERVOUS SYSTEM : 

Patient is conscious coherent and cooperative

Speech is normal 

No signs of meningeal irritation

Cranial nerves - intact 

Sensory system normal 

Motor system:

Tone - normal 

Bulk - normal 

Power - bilaterally 5/5 

Deep tendon reflexes 

Biceps : ++

Triceps : ++

Supinator: ++ 

Knee : ++

Ankle : ++

Superficial reflexes - normal 

Gait - normal

Provisional diagnosis :

Arthralgia ? Tendonitis 

Investigations 

X ray C spine lateral view 

  X ray sacroiliac