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










Comments

Post a Comment

Popular posts from this blog

Gm case ( 76 yrs female)

Image
  GENERAL MEDICINE  23-11-22 This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the  comment box below. DATE OF ADMISSION: 22-11-22 A 76 year old female housewife from narketpally came to opd with CHIEF COMPLAINTS OF: . Difficulty in breathing  . Rashes on abdomen  HOPI:  . The patient was apparently asymptomatic 1 year back and and developed shortness of breath ( grade 3) which used to subside once she sits . Aggrevating factors- cold environment,  relieving factors- medications. . Not associated with orthopnea and paroxysmal nocturnal dyspnoea  . Around 10 days back patient developed multiple lesions on the left flank of abdomen,  sudden in onset , progressed to hyperpigmented Macules with crusting, no aggrevating or relieving factors , complaints of left iliac fossa pain radiating  to left hypoch
Read more

158 - Akhila.I( prefinal osce and learning points)

Image
Dec 5th 2023 Blog link- http://inavoluakhila.blogspot.com/2023/12/long-case-elog-medicine.html Osce questions  1. How does cpap work CPAP machines  possess a motor that pressurizes room temperature air and delivers it through a hose connected to a mask or tube worn by the patient . This constant stream of air opens and keeps the upper airway unobstructed during inhalation and exhalation. 2. Diabetic neuropathy pathogenesis  uncontrolled high blood sugar damages nerves and interferes with their ability to send signals , leading to diabetic neuropathy. High blood sugar also weakens the walls of the small blood vessels (capillaries) that supply the nerves with oxygen and nutrients. Learning points from my case discussion 1.how to check and what are the diagnostic criteria for obstructive sleep apnea  2.Various genetic inheritences like polygenic inheritance,autosomal dominant and xlinked dominant and if there is any genetic susceptibility of CAD in patient 3.does weightloss h
Read more

LONG CASE (elog medicine)

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.                                                                                      With the reference of our senior https://mvineelarollno90.blogspot.com/2023/11/65-y-female-with-co-fever-since-4-days.html 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 Chi
Read more