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CASE: A 56yr old male , sales manager by occupation , resident of miryalaguda ,came to the opd with cheif complaints of easy fatiguability on excertion since 30 days HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 30 days back then he developed fatigue on excertion which was insidious in onset , gradually progressed to the present stage. ( He was able to walk 500m initially.... But now he can only walk 100m ) which was associated with Dyspnea on excertion , palpitations and body pains. No complaints of - chest pain , cough , fever , hematuria . PAST HISTORY: No H/o DM , HTN, Asthma, Epilepsy, CAD FAMILY HISTORY: No significant history PERSONAL HISTORY: Diet - Mixed Appetite - Normal Sleep - Adequate B&B - regular No Addictions GENERAL EXAMINATION: Patient was conscious coherent and cooperative  Moderatly built and nourished VITALS: Pulse - 94 bpm Regular Normal volume  BP - 100/70 mm hg Respiratory rate - 29 cpm  OTHER SIGNS: Pallor - Present Icterus - absent  Cy

LONG CASE: A 50 year old female patient a resident of Nalgonda, home maker came to the OPD with chief complaints of pain and stiffness in several joints since 1 year. HISTORY OF PRESENT ILLNESS She was apparently asymptomatic 10 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(MCP joints) of right hand with limitations of movements at the joints.  Then within 6 months of onset the disease progressed to involve other joints of the right hand and left hand as well(wrist joint and elbow joint)  Within 4 years of onset she started feeling pain in the joints of the feet and ankle joint.  Since 3 months the pain became unbearable limiting her activities The pain was insidious in onset, slowly progressive dull aching type of pain, non radiating, associated with swelling, stiffness and limitations of movements in the involved joints. Stiffness and pain was more in the first 1 hour of waking up and gradually improved on movement. There are few exacerb