Patient Coming to Clinic for Arthritis in Knee - Case Study Example

Mr. P has not been suffering from any other disease apart from the problem with joints pain and swelling. He has never been admitted to hospital. His knees had swollen again in January 2009 but he never took any medicine, the problem went away by its own. Surgical History: Mr. P has never undergone any surgery in his life time. Even after suffering from knee and joint pain he did not go for medical check-ups. Allergies: Mr. P develops hey fever which heals itself after a few days. He develops nose irritation, itching, sneezing, and the eyes turn red.

Medications: Mr. has not visited the hospital for examination but buys antibiotics like aspirin and pain killers from shops. Review of Systems: Mr. P developed the following symptoms; abdominal pain, difficulty swelling, malaria, tenesmus, nausea, diarrhea, and unintentional weight loss. Head: Sometimes he develops spear headache. Eyes: He has developed red and irritating eyes. He also has eye pain and experiences visual changes Ears: Mr. P has stuffy, painful and tinnitus ears. Gastrointestinal: Reports nausea today.

Some days he develops nausea as well as vomiting. Neurologic: Mr. P does not have a problem with smell, taste, seizures, and faints. He developed difficulties in sight and hearing. Physical Exam: Mr. P is physically fit. Vital Signs: The vital signs have no problem. He has normal blood pressure, respiratory rate, and heart rate. Temperature 38 degrees census Fingerstick He has sugar level 4. He is alert and able to recognize the place people and time. PERLA The eye has no problem. It has a round pupil, reactive to light and able to focus objects at a close and far distance.

ENT: He has clear ears, clear nose, and a clear throat. Weber test: Rinne both ears test showed that he has a loss of sensorineural in the left ear but the right ear was normal.