THESIS MODEL CASE


 Note - This is an a online e log book to discuss our patient's 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 centred online learning portfolio and your valuable inputs on the comment box is welcome.

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.

Case sheet:

Chief Complaints:
A 65yr old male, resident of NALGONDA, labourer by occupation came to OPD with chief complaints of  pain,tingling in the back of left thigh since one month 

pain in the left hip since 1month  

pain in the both knees since 6 months 

History of presenting illness :
Patient was apparently asymptomatic six months back then he developed pain in the both kness insidious in onset progressing in intensity to a stage where he is unable to walk without stick and unable to get up from sitting position and unable to sit down now he is complaining of pain in the back of left thigh radiating upto the knee posteriorly 
no h/o trauma   

Past history:
Patient is a known case of hypertension since 6 months on unknown medication and dm-2 since 1 year on unknown medication 
N/K/C/O,  Asthma, TB, CAD 

allergic history : Not significant

Drug history: not significant

Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate 
Bowel and bladder movements : regular 
Addiction : occasional alcohilic, non  smoking

Family history: Insignificant 

General examination :
WT -67KGS
HEIGHT:-170CMS
BMI :-23.2
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema

Vitals:
Temperature : 98.6F
Pulse rate: 84bpm
Respiratory rate: 18cpm
BP: 150/100 mm Hg
SpO2: 98


Systemic examination :

Respiratory system :
Vesicular breath sounds heard
No additional breath sounds heard

Cardiovascular system :
S1 S2 heard
No murmurs

Abdomen:
Soft, non tender
OBESE

CNS:
No neurological deficits seen

JOINT EXAMINATION 
Local raise of temperature positive in both knees 
crepitus positive in both knees 
swelling absent in both kness 
patellar tap negative in both kness 




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