75 yr old male came to opd with chief complaints of

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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.

A 75yr old male from nalgonda came to opd with,

CHIEF COMPLAINTS: pain in abdomen since 4 months

                   bilateral knee pain since 20yrs

HISTORY OF PRESENTING ILLNESS:patient was apparently asymptomatic 20 yrs back then he developed unilateral knee pain which was insidious in onset gradually progressive to both limbs,throbbing type pain.

Patient is unable to stand from sitting position or sit from  standing  position,walking with support since 5 to 6 yrs

No pain on rest aggrevated on standing and walking

History of pain around umbilicus region,gradually progressive insidious in onset ,burning type, aggrevated after eating spicy food since 4 months after 1 hr of eating  food ,resolves spontaneously after 2 hrs

No history of weight loss or weight gain,nausea,vomiting,constipation,diarrhoea,

No history of headache,dizziness,burning  micturition,malena.

. HISTORY OF PAST ILLNESS:

. K/c/o diabetes type 2 since 2 yrs not on medication

. Not a k/c/o HTN,CVA,CAD,TB,ASTHMA

. TREATMENT HISTORY:insignificant. 

. PERSONAL HISTORY: His daily routine 20 years ago  was he use to wake up at 6am in the morning and have tea and he use to look after his agriculture land and at 9a.m he use to have breakfast and continued his work till lunch at 2 o'clock then he use to rest for a while and continued his work till dinner time at 8 pm

After 8 he used to spend some time with family before going to sleep at 10  clock.

But due to unbearable knee pains he stopped working since 10 yrs.

 He smoke 1 pack of beedi since 40 yrs

Dietary history

Breakfast - 4 idli or 1Dosa

Lunch - rice with Dal,vegetables and curd

Evening snacks- tea and biscuits

Dinner- chapathi with vegetable curry

Mixed diet

Appetite normal

Sleep adequate.

. FAMILY HISTORY:

. No significant family history

. GENERAL EXAMINATION :

, 

. Patient was conscious coherent co-operative

 

Pallor - no

No icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS

BP- 100/70mmhg

Bp - 90/60mmhg

PR -68 bpm

RR-22cpm

Spo2 98% at room air 

Temperature - afebrile

System examination

ABDOMEN : 

INSPECTION: 

Shape – scaphoid

Flanks – free ,Umbilicus – central, Shape-inverted

Skin – no scars

Dilated veins – absent

PALPATION:

Superficial palpation-no tenderness

Deep palpation:

Liver:not palpable

Spleen:not palpable

Kidney: not palpable

PERCUSSION : Tympanic note heard all over the abdomen.

 

 

AUSCULTATION:

Bowel.sounds heard.

CVS: S1 S2 heard , jvp not raised,apex beat pounding , heart sounds normal,no murmurs

RS: BAE present ,NVBS heard.

 Trachea central

Chest movements normal

CNS: NFND,higher mental functions normal.

. LOCAL EXAMINATION OF KNEE:

   

No crepitus

Flexion deformities present.

Movements restricted on extension.

No swelling 

No tenderness

No redness

Provisional diagnosis: non ulcer dyspepsia

Bilateral.osteoarthtitis.

Investigations:

   

TREATMENT:

 TAB RAZO D 40 MG PO/OD 7AM

 TAB ULTRACET 1/2 TAB QID

 SUP. ALKASTON B6 PO/BD,10ML IN ONE GLASS OF WATER.

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