GENERAL MEDICINE

General Medicine

August 5th, 2023

Case scenario.

    Hi, I'm aishwarya.s 3rd bds student. This is an online elog book to discuss our patient health data, after taking his consent. This also reflects my patient centered online learning portfolio.

Case history: 

Patient details: 

      A 63 year old male occupation by farmer , presented with the

Chief complaints: 

  Neck pain, back pain, knee pain, since 6 months. 

History of present illness: 

    Patient was apparently asymptomatic 6 months ago then he had neck pain which is non radiating and there is no restriction of movements. And also complains of back ache since 6 months which is radiating to both the lower limbs and has tingling sensation. Also complains of knee pain from 6 months.

History of past illness:

        No know history of diabetes mellitus, 

Hypertension, epilepsy, tuberculosis, asthma, and thyroid disorders and no CVA.

Personal history:

  Occupation: farmer

  Appetite: normal

   Diet : mixed

   Sleep : Normal

  Micturition: normal

  Bowel movement: regular

Allergies: no

     Habits: drinks occasionally.

  

Family history: 

      Not significant.

General examination:

       Built : normal

  Patient was Consious, co operative and coherent.

 Pallor: no

 Icterus: no

 Cyanosis:  no

 Lymphadenopathy: no

 Edema: no

Vitals:

    Temperature: 98F

     Pulse rate : 88/min

     Respiratory rate : 22/min

     Bp : 136/98 mmHg

      

Systemic examination:

    CVS: cardiac sounds - s1 s2 positive

    Respiratory system: normal

    Position of trachea: central

    No wheezing and dyspnea.

    Breath sounds: normal

    Abdomen:  no tenderness.    

Provisional diagnosis: 

      Osteoarthritis of knee.