GENERAL MEDICINE CASE STUDY

CH.LAHARISHA
ROLL NO.28
This is an online e log book to discuss our patient 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

A 76yr old male came to OPD with the chief complaints of eye pain and blurred vision.


CHIEF COMPLAINTS:
Pain in the right eye and blurred vision 
Knee pains occassionally
Epigastric pain 
 
HISTORY OF PRESENTING ILLNESS:
 Patient was apparently asymptomatic 1 yr back then he started developing right eye pain ,left eye has no problems and blurred vision.he used to get knee pains occassionally for one year for which he used medications .he developed epigastric pain four months back .

HISTORY OF PAST ILLNESS:
 Not a k/c/o of DM ,HTN EPILEPSY,TB, CARDIOVASCULAR DISEASES,asthma 
He used medication for knee pains and throat pain prescribed by a local doctor
No history of surgeries .

FAMILY HISTORY:
No relevant family history

PERSONAL HISTORY:
married
Mixed diet 
Normal appetite 
Normal bowel and bladder movements
No history of allergies
Normal sleeping habits
Addiction:he is a teetotaler
No smoking
 
PHYSICAL EXAMINATION:
GENERAL EXAMINATION:
No pallor
No icterus
No cyanosis
No clubbing
No pedal edema
No lymphadenopathy
No malnutrition

VITALS:
Temp:afebrile
Pulse:70beats/min
BP:130/80
RR:17/min
GRBS:101mg%
 
SYSTEMIC EXAMINATION:
CVS:
S1and S2 heard
No thrills
No murmurs

RESPIRATORY SYSTEM:
No dyspnoea
No wheeze
Trachea is central
Vesicular breath sounds

ABDOMEN:
No tenderness
No palpable abdominal mass
No hepatosplenomegaly
No spleenomegaly
No bruits
No bowel sounds

CNS:
Conscious, coherent
Co operative
Speech is normal
No neck stiffness
No kernigs sign
Sensory system and motor system is normal
Reflexes are normal 

PROVISIONAL DIAGNOSIS:
             Acute gastritis?
  INVESTIGATIONS:






TREATMENT:
TAB MVT ONCE A DAY
TAB PAN 40 MG ONCE A DAY
TAB ULTRACET 1/2 FOUR TIMES A DAY
 





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