A 65 yr old man..

This is online E book to discuss our patients health data shared after taking his guardians informed consent form


I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings investigations and come with a diagnosis and treatment plan.

Case scenario:
A 65 yr old man came to OPD with chief complaints of backache and pain in knees while climbing stairs

CHIEF COMPLAINTS 
Chronic back pain
Pain in knee joints
Bilateral pedal edema
Burning micturition and pus in urine 
Constipation 


HISTORY OF PRESENTING ILLNESS 
 Patient was apparently asymptomatic 1yr ago and developed chronic back pain  and pain in knee joints since 1yr. Bilateral pedal edema since 1yr(non pitting type)
Constipation since 4 months. Stool passage is once in
4 to 5 days.
Burning micturition and pus in urine since 2 months

History of past illness 

 He was not a known case of Diabetes mellitus,Hypertension, TB,Asthma, and Epilepsy 
No h/o of previous surgeries. 

Personal history
Married
Diet: mixed
Bowel is irregular ( Constipation - once in 5 to 6 days )
Bladder movements: oliguria and burning micturition. 
No known allergies 
Alcoholic ( once in a week 1-2 glasses )
chronic smoker since 20 yrs and stopped smoking 4 months back.
Drug history
Used pain killers since 40 yrs 

Family history 
No significant family history 

Physical examination 

General examination 
Moderately built 
No pallor 
No icterus
No cyanosis
No clubbing 
No lymphadenopathy 
Bilateral pedal edema
 
Vitals
Temperature: afebrile 
Pulse rate : 76/ min
Respiratory rate : 20/ min
BP : 90/70 mmhg

Systemic examination 

CVS
S1 and S2 are heard
No thrills 
No cardiac murmurs 

RESPIRATORY SYSTEM 
No Dyspnoea
No wheezing 
Position of trachea is central
Breath sounds are vesicular 

ABDOMEN
Shape : scaphoid 
Lower abdominal pain
No palpable mass
No splenomegaly and hepatomegaly 

CNS
Conscious and coherent 
Cranial nerves , motor system and sensory system are normal
No neck stiffness 
No kernigs sign
Speech : normal

Musculoskeletal system 
Normal

Provisional diagnosis 
Osteoarthritis of knees ( bilateral )
Secondary to cystitis 
Drug history
Used pain killers since 40 yrs 

Family history 
No significant family history 

Physical examination 

General examination 
Moderately built 
No pallor 
No icterus
No cyanosis
No clubbing 
No lymphadenopathy 
Bilateral pedal edema
 
Vitals
Temperature: afebrile 
Pulse rate : 76/ min
Respiratory rate : 20/ min
BP : 90/70 mmhg

Systemic examination 

CVS
S1 and S2 are heard
No thrills 
No cardiac murmurs 

RESPIRATORY SYSTEM 
No Dyspnoea
No wheezing 
Position of trachea is central
Breath sounds are vesicular 

ABDOMEN
Shape : scaphoid 
Lower abdominal pain
No palpable mass
No splenomegaly and hepatomegaly 

CNS
Conscious and coherent 
Cranial nerves , motor system and sensory system are normal
No neck stiffness 
No kernigs sign
Speech : normal

Musculoskeletal system 
Normal

Provisional diagnosis 
Osteoarthritis of knees ( bilateral )
Secondary to cystitis 
Drug history
Used pain killers since 40 yrs 

Family history 
No significant family history 

Physical examination 

General examination 
Moderately built 
No pallor 
No icterus
No cyanosis
No clubbing 
No lymphadenopathy 
Bilateral pedal edema
 
Vitals
Temperature: afebrile 
Pulse rate : 76/ min
Respiratory rate : 20/ min
BP : 90/70 mmhg

Systemic examination 

CVS
S1 and S2 are heard
No thrills 
No cardiac murmurs 

RESPIRATORY SYSTEM 
No Dyspnoea
No wheezing 
Position of trachea is central
Breath sounds are vesicular 

ABDOMEN
Shape : scaphoid 
Lower abdominal pain
No palpable mass
No splenomegaly and hepatomegaly 

CNS
Conscious and coherent 
Cranial nerves , motor system and sensory system are normal
No neck stiffness 
No kernigs sign
Speech : normal

Musculoskeletal system 
Normal

Provisional diagnosis 
Osteoarthritis of knees ( bilateral )
Secondary to cystitis 

Investigations:-

Treatment

Tab. OFLOX-OZ 200 mg po/Bd
Tab. ULTRACET1/2 Tab. Po/qid
Tab. DYTOR 10mg po/od mrng
Tab. PREGABA -M 75 mg po/hs
Syrup CREMAFFIN 15 ml
Syrup CITRALKA-B6 5ml
Injection: optineuron lamp+100 ml normal saline
Tab. PANTOP 40 mg

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