Personal ID
Name Hameda Jasem Mohammed
Age  53 years 
Gender  female 
Occupation  teacher 
Blood group  O-
Martial status  Married 
Chronic diseases   OA, Diabetes type 2

I will take history and examination then i will discuss the timeline of the patient condition improvement or Worsening including complications and investigations with treatments. 


History taking:
1-chief complaint
Bilateral knee pain and stiffness with polyuria and fatigue 

2-history of presenting illness
The patient presented with localized bilateral knee stiffness and gradual aching deep pain increase in the morning specially with prolonged sitting or walking and making movements difficult for her to do normal activities and progress sometimes to even blocking the two joints, relived by rest or medications but not always in the same degree. She also reports an blurred vision and polyuria with generalised fatigue, she says that these symptoms appear after eating sweats even with sometimes with small meals even with treatment . She has also felt more tired and lethargic in recent months. No fever or chills. No trauma or falls. Weight and appetite are stable.


3-Past medical history
DM type 2 from 9 years and use metformin for it, OA from 11 years and use NSAIDS with supplements for it. 

4-systemic reviews
No any history of endocrine or cardiorespiratory diseases 
GIT   no any significances
ENT   normal
UROGENITAL  no any significances
CARDIORESPIRATORY  no significances 
ENDOCRINE  no history of any endocrine disorders


5-family history her mother and most of her brothers and sisters with diabetes 

6-drug history metformin and ibuprofen 

7-social history
She continues to teach, not smoker and mother of 4 boys, and get support of them with her husband, 

_____________________________________________________

Clinical examination:
Vital signs
BP, Temp, RR,PR, Spo2  
120/80,   36.8 C,  75, 97%

General inspection
She is Alert and oriented, appears tired. Movements slow due to joint pains but no distress. Obese and sweating but with normal breathing. no lesions or any abnormal appearance, no any hypersensitivity manifestations.

i'll explain inspection, palpation & auscultation to each region or system:


Head/Neck: Normocephalic, no central cyanosis and normal face. on the the right side of the neck there was lump : soft and spongy about 2 cm in length, difficulty in swallowing or breathing not detected but the patient reports that if there's infection in her throat, she suffer from difficulty in breathing and Experiencing more episodes of choking. 

Extremities: normal hands and foot, no any lesion or abnormalities in nails and palm or dorsum of the hand, the foot also clear in two sides with no complications of diabetes or peripheral cyanosis. Pulse normal and regular. 

Chest: Equal air entry bilaterally, normal vesicular breath sounds. Faint expiratory wheeze. 

Heart sounds normal S1, S2, no murmurs. Rate regular.

Abdomen: Soft, non-tender. No organomegaly or masses. Bowel sounds normal. 

Musculoskeletal: Diffuse joint crepitus. Stiffness and pain on passive range of motion of knees and hips, worse with internal rotation. Tenderness over medial joint lines bilaterally.  joint slightly swelling, no redness or warmth. Strength and sensation grossly intact in lower limbs. Reflexes 2+ bilaterally. 

The remainder of the examination including cardiovascular, gastrointestinal and neurological system are grossly normal. 

Provisional Diagnosis: 
-Worsening osteoarthritis of knees and hips 
-Suboptimal diabetes control.

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The Timeline Follow Up 
The patient has been diagnosed with diabetes type 2 and then diagnosed by osteoarthritis after year from her diagnosis of diabetes (the patient did not get consultant to rheumatologist To the extent that NSAIDs was not affect on her, In spite of OA was earlier by 2 years before diabetes). 
The patient revealed that she has not all the investigations paper of the first time but she found the Hba1c (7%), the random was (160mg/dL) and the anterior X-ray picture of her left knee indicated (slightly narrowing in the medial side of the knee - asymmetrical - with subchondral sclerosis) . the pain of her ankle progress to involve the right knee and prone to be continuous specially standing to siting Or vice versa and not affected by reliving factors and radiated to ankle specially in , she visited multiple doctors and same medications prescribed with little benefits, after that the right knee symptoms increased a OA symptoms also. 

In 2022-5-13 the patient had been in consult with Internist about Dysphagia during fever and can't talk so she was sent for Ultrasound of the neck that revealed (5.2 × 2.4 cm circumscribed margins of hypoechoic nodule  in the right side of thyroid with mild vascularity and there wasn't microcalcifications, no lymphadenopathy)  with no symptoms or hormonal changes (TSH and T3, T4  are all nornal), the doctor gave her levothyroxine and she taked it for two days and leave it due to side effects. After week, The symptoms of Dysphagia decreased relatively with fever decline thqt may exacerbate the thyroid adenoma compression. 


in 2022-11-21  the patient had a consultant with endocrinologist about her diabetes due to increases Glucometer readings about (160-200 mg/dL) and suffering thrist, frequent urination and blurred vision even with treatment so the doctor changed her medication after HbA1c (7.5%) so he turned her to metformin+glibenclamide  once daily, after week the glucometer readings decreased to about (110 mg/dL) in fasting. She reported an episodes of thrist and readings of hypoglycemia (80 mg/dL) after period of prescription. 





2023-1-18  the patient state was good for diabetes, but the doctor told her to check her diabetes with him after month so after 2 months she get consultant with him about her diabetes and thyroid adenoma, the tests of diabetes was all normal in compensated diabetic range of readings without any symptoms of blurred vision or thrist, sweating, the doctor was concerned about her thyroid so he sent her for neck CT that revealed (4.2 × 3 cm right thyroid nodule that is well-circumscribed and solid, with no calcifications or invasion of surrounding tissue. The nodule is iso-dense with the surrounding thyroid tissue) and the TSH, T4 and T4 levels was normal, the doctor Convinced her about levothyroxine and decreased the dosage. Then the patient visited rheumatologist about her right and left knee OA and the doctor do to here physical examination of her legs and gave her NSAIDs cream and pills and gabapentin and turned her to Physiotherapy for 5 sessions, the patient said that after one day the drugs make her drowsy and confused so stopped them and stayed on nsaids cream that didn't cover the pain relief effect, the physiotherapy helped her and make differences to declining of pain.  She also ended the course of levothyroxine with 28 tablets and each tab is for one day.