72F suffering from Arthritis.

 

2nd May 2023

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 72-year-old female, resident of West Bengal, and Home Maker by occupation. The following history was taken through a telephone conversation. The patient was explained about confidentiality and written consent was taken to create the following case report.

This case report aims to record the patient's journey.

CHIEF COMPLAINTS:-

- Patient complains stiffness of joints since 2005.

- She also complains of having UTI since 2008.

- The patient reports having eye pain in the supra-orbital region since last month.

History of present illness:-

Before the year 2005, the patient reports to have observed stiffness of the joints of her arm starting at the right side, specifically at her wrist joint. This stiffness has progressively worsened at the year 2005, where the patient describes not being able to move the wrist joint of her right hand. The pain is reported to increase especially during winter season (specifically noticeable at the hip and shoulder region of the patient), and while sitting (noticeable in the hip region). The pain decreases when the patient is asleep. The pain is insidious on onset and has progressively spread from the wrist region to the neck region. The patient reports that the joints in the lower limb are not affected aside from the occasional leg strain which occurs during sleep. At present, due to regular exercise and medications, the patient reports that the pain is at manageable levels. 

From 2008 onwards, the patient reports to have had UTI which lasts till today. It was insidious in onset and the patient was drinking less water and frequently experiencing fever approximately 3-4 days intermittently. There was no burning micturition, however, the patient complains of incomplete micturition and oligouria. The pain is reported to decrease once the patient drinks alot of water and takes her prescribed medication. however, even after being prescribed medications, this UTI episode continues to happen every year till date for 1-2 days.

 Last month, the patient reports to be experiencing eye pain roughly in the supra orbital region on the left side. The pain is described to be sharp, almost similar to an "electric shock" type. This pain occurs at an interval of 1 to 2 days. There is no associated headache with the eye pain. The onset of the pain is insidious.

History of past illness:-

The patient has no history of TB, DM, Asthma or Epilepsy.

The patient has a history of having high Blood pressure. 

In the year 2005, the patient has had a surgery on the right hand in the wrist region. 

Personal history:-

Water intake:- normal

Appetite:-normal

Diet:- mixed

Bowel and bladder movement:- normal

Addictions:- none

Alcohol:- none

Smoking:- doesn't smoke

Allergies:- none. 

Exercise status:- Patient exercises 45 minutes accumulative of 3 sessions on a daily basis. 

Reports:-