B/L KNEE OSTEOARTHRITIS K/C/O CAS S/P PTCA 13 YRS BACK HYPERTENSION DIABETES MELLITUS

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74 YR OLD MALE PATIENT WITH C/O B/L KNEE PAIN SINCE 2 YEARS

C/O TINGLING OF FINGERS OF B/L HANDS SINCE 6 MONTHS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK THEN HE DEVELOPED KNEE PAINS OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AGGREVATED ON PROLONGRD SITTING RELIVES ON WALKING 

TINGLING OF TIPS OF BOTH HANDS SINCE 6 MONTHS

NO H/O POLYURIA,POLYDIPSIA,NO H/O BURNING MICTURITION

NO H/O FEVER,COUGH,COLD,HEADACHE,GIDDINESS,CHEST PAIN,SOB ,PEDAL EDEMA

PAST HISTORY:

K/C/O CAD S/P PTCA 13 YRS BACK ON ECOSPIRIN 75 MG+CLOPIDOGREL 75 MG+ATROVASATIN 20 MG

N/K/C/O HTN,DM,SEIZURES,THYROID DISORDERS,ASTHMA

PERSONAL HISTORY:

DIET- MIXED

APPETITE- NORMAL

BOWEL AND BLADDER MOVEMENTS- REGULAR

SLEEP- ADEQUATE

GENERAL EXAMINATION:

PT IS C/C/C

AFEBRILE

BP-140/80 MMHG

PR- 86BPM

RR-22CPM

SP02- 96% AT RA

GRBS- 133 MG%

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD

RS BAE +

GIT SOFT NT

CNS NFND

INVESTIGATION:

UREA 31 mg/dl 50-17 mg/dl  CREATININE 1.3 mg/dl 1.3-0.8 mg/dl  URIC ACID 7.0 mg/dl 7.2-3.5 mg/dl  CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 3.2 mg/dl 4.5-2.5 mg/dl  SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 4.5 mEq/L 5.1-3.5 mEq/L  CHLORIDE 104 mEq/L 98-107 mEq/L  LIVER FUNCTION TEST (LFT)   20-12-2023 03:59:PM  Total Bilurubin 0.60 mg/dl 1-0 mg/dl  Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 16 IU/L 35-0 IU/L  SGPT(ALT) 18 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 171 IU/L 119-56 IU/L  TOTAL PROTEINS 7.2 gm/dl 8.3-6.4 gm/dl  ALBUMIN 4.0 gm/dl 4.6-3.2 gm/dl  A/G RATIO 1.3    COMPLETE URINE EXAMINATION (CUE)   20-12-2023 03:59:PM  COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN Nil    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 2-3    EPITHELIAL CELLS 3-4    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil   HBsAg-RAPID   20-12-2023 03:59:PM Negative     Anti HCV Antibodies - RAPID   20-12-2023 03:59:PM Non Reactive     POST LUNCH BLOOD SUGAR   20-12-2023 03:59:PM 279 mg/dl 140-0 mg/dl

DIAGNOSIS: B/L KNEE OSTEOARTHRITIS K/C/O CAS S/P PTCA 13 YRS BACK  HYPERTENSION DIABETES MELLITUS TREATMENT:

TAB ECOSPIRIN GOLD 20 OD

TAB HIFENAC PO BD

TAB PAN 40 MG PO OD

TAB SHELCAL 500MG PO OD

TAB TELMA 40 MG PO BD

TAB GLIMI M1 PO OD

ADVICE AT DISCHARGE:

TAB ECOSPIRIN GOLD 20 OD

TAB HIFENAC PO BD

TAB PAN 40 MG PO OD

TAB SHELCAL 500MG PO OD

TAB TELMA 40 MG PO BD

TAB GLIMI M1 PO OD