Osteoarthritis secondary to oliguria and constipation

This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.

 

Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

 

This E-log also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.


CASE SCENARIO:

A 65 year old male presented to the orthopaedic OPD with complaints of inability to climb stairs, pain in knees and ankles oliguria and pain during defecation.


COMPLAINTS AND DURATION

  1. Chronic back pain since 1 year
  2. Pain in the knee joints and along the chin for 1 year
  3. Burning micturition and oliguria since 6 months
  4. Constipation 6 months. Once in 5 to 6 days passage of stool
  5. Back pain since 1 year
  6. BURNING FEET since admitting?
  7. Pins and needles generally on the body?


HISTORY OF PRESENT ILLNESS

Patient apparently asymptomatic one year ago. He had a case of trauma on his back last year since then he has been complaining about his current complaints


HISTORY OF PAST ILLNESS

  • Not a K/C/O HTN, DM, asthma, epilepsy


TREATMENT HISTORY

  • Self administration of pain killers since 40 years
  • Chronic use since last 3 years


PERSONAL HISTORY

  • Married

  • Appetite - lost

  • Bowels- reduced. Once every 5 to 6 days

  • Micturition - Reduced

  • No known allergies

  • Addiction to alcohol, 1 to 2 glasses everyday of branded liquor. BD regular habit, upto 10 to 15 a day


FAMILY HISTORY

  • No significant family history


PHYSICAL EXAMINATION

  1. GENERAL

  • Weight - 50 kgs

  • Pallor - No

  • Icterus - No 

  • Cyanosis - No

  • Clubbing of finger/toes - No

  • Lymphadenopathy - No

  • Oedema - No 

  • Malnutrition - yes 

  • Dehydration - No

  • Temperature - afebrile 

  • Pulse rate 76 b/min

  • Respiration rate - 20/min

  • BP 90/70 mmHg 


SYSTEMIC EXAMINATION 

  1. CARDIOVASCULAR SYSTEM

  • Thrills - No 

  • Cardiac sounds - S1 , S2 positive


  1. RESPIRATORY SYSTEM 

  • Dysponea - No 

  • Wheeze - No

  • Position of trachea - Central 

  • Breath sounds - Vesicular 

  • Adventitious - Rhonchi 


  1. ABDOMEN

  • Shape of abdomen - Scaphoid


  1. CENTRAL NERVOUS SYSTEM 

  • Level of consciousness 

  1. Alert

  2. Stuporous 

  • Signs of meningeal irritation

  1. Neck stiffness - no

  2. Kerning’s sign - no

  • Cranial nerves - normal 

  • Motor system - normal

  • Sensory system - normal 

  • Glasgow system - normal 

  • Cerebral signs

  1. Finger nose coordination - Yes

  2. Knee Heel In-coordination - Yes


F.MUSCULO SKELETAL SYSTEM - normal 


G. SKIN - normal

 

H. EXAMINATION OF BREAST - normal


I. EXAMINATION OF ENT - normal


J.EXAMINATION OF TEETH AND ORAL CAVITY - normal


K. EXAMINATION OF HEAD AND NECK  - normal


PROVISIONAL DIAGNOSIS/ DIAGNOSIS 

  1. Osteoarthritis B/L of the knees
  2. Secondary to AKI
  3. Constipation


TREATMENT
  1. Tab. ULTRASET BD
  2. Tab. PAN 40 OD
  3. Physiotherapy 
  4. Tab. DYTOR 10mg OD
  5. SYRUP. LIQUID PARAFFIN TID 
  6. INJ. OPTENURON OD




INVESTIGATIONS

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