80 year old male resident of Narketpalli came with knee joint Pain

 April 19,  2023 

Hi, I am Tadaka Shivaram krishna , 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”I've 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 a diagnosis and treatment plan.

CHEIF COMPLAINTS 

Patient with knee pain  and complaining of dragging type of feeling on walking  

History of present illness 

Bilateral knee  joint  pain on 2 years 

SOB : 6 months 

Indigestion : on and off 5 months 

Patient  apparently asymptomatic a year back then he develeop 

  Bilateral knee joint pains,  not seen  any swelling’s 

 Restriction of flexion movement 

 Pain aggravates on walking and is relieved on taking  rest and medication

 No Fever 

SOB 6 months  grade ||

No cough ( before dry cough ) 

Chest pain -  negative 

Sweating  - negative 

Fever - negative 

Pedal Edema - Postive  pitting 

Edema increase  up to ankle while walking and relives on  elevation of limb  

during rest  

Decreased urine output  - No

Burning micturition  - since 5 months 

Indigestion and burning sensation after food intake 

Abdominal discomfort  - yes 

Bloating on and off 

Constipation -ve 

Loose stools -ve 

Vomitings. -ve 

    

HISTORY OF PAST ILLNESS 

K/C/O  Hypertension :  1 year  stopped one month back 

K/C/O.  TB  :  1 year back cured on medication 

N/K/C/O.    DM || , CVA ( cerbro vascular accident ) 

                 CAD( coronary  artery disease) 

                 Epilepsy, Asthma 

TREATMENT HISTORY 

 

Diabetes - No 

Hypertension - Yes  since 1 year 

Cad - No 

Asthma - No 

Tuberculosis - Yes 

Antibiotics - No 

Hormones - No 

Chemo / radiation - No 

Blood transfusion - No 

Surgeries - No 

Other - No 

PERSONAL HISTORY 

Married 

Occupation - farmer 

Appetite - normal 

Veg / non  Veg  - mixed 

Bowels - regular 

* Micturition -  normal 

Known allergies - none 

  

Habits and addictions 

  a )  Alcohol - occasionally 

b )   Tobacco -  no 

c )   Drug use -  no 

d )   Betel nut - no 

 e ) Betel leaf  ( Pan ) - no 

   

FAMILY HISTORY 

  

Diabetes - no 

Hypertension - no 

Heart disease - no 

Stroke - no 

Cancer - no 

Tuberculosis  

Asthma - no 

Any other hereditary diseases  - no 

Psychiatrist illness - no 

Sibling history  - no 

Any other  - no 

        

Plantars     -   Flexor 

CEREBEILAR SIGNS 

Finger -  Nose   In - Coordination - No 

Kneel - Heel    In - coordination - No 

GAIT - HEMIPLEGIC  / SLOW , 

             SHUFFLING /   ATAXIC /  HIGH STEPPING   

   

GENRAL EXAMINATION 

  

NO PALLOR 

NO CYANOSIS

NO ICTERUS

NO CLUBBING OF FINGERS 

PROVISIONAL DIAGNOSIS 

 BL knee joint pain 

  

EVALUATION - OSTEOARTHRITIS 

 

SOB -  decrease evaluation  - K/C /O 

TB  ( relived ). One year  back 

Investigations orders 

Hemogram 

Rft 

LFT 

ECG 

2d echo 

X ray