Gm case ( 80yrs male)

 

April 19, 2023
An 80 year old male came to OPD with chief complaints of
 
Bilateral knee joint pains since 2 years
Sob since 6 months
Indigestion on and off since 5 months 
HOPI:
Patient was apparently asymptomatic 2 years back then he developed bilateral knee joint pains not associated with any swelling,restriction of flexion movement.pain aggrevates during walking and relieved on taking rest and medication.not associated with fever 
Then he developed SOB since 2 months which is of grade-2.It is not associated with cough(before dry cough)
It is associated with pedal edema which is pitting type upto ankle.It is increasing while walking and relieved on elevation of limb and during rest.
not associated with palpations,chest pain,sweating,fever
Not associated with decreased urine output,burning micturition.
Then he developed indigestion with burning sensation after food intake.relieved on taking medication.
It is associated with abdominal discomfort,bloating(on and off).
It is not associated with constipation,loose stools,vomitings,fever,regurgitation
Past history:
He is a k/c/o DM since 1 year
HTN since 2 year
He is a k/c/o tb(relieved)
Not a k/c/o thyroid,epilepsy,asthma
PERSONAL HISTORY:
Personal History -
Married
Occupation- Farmer
Diet: mixed
Appetite: normal
Bowel and bladder : Normal
Addictions: occasional alcohol drinker
Family History -
No similar complaints in the family. 

General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent and cooperative.
Built & nourishment-Moderate
No pallor 
No cyanosis
No icterus
No clubbing
No lymphadenopathy






 



Systemic Examination -
CVS : 
S1 S2 present
No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

ABDOMEN:
Shape of abdomen: scaphoid.
Soft, non tender, no organomegaly present.
No rigidity or guarding.

CNS :
NFND, HMF intact
Reflexes - Normal










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