16/12/22
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Sanidha Singh
206
CHIEF COMPLAINTS:
Right knee pain and swelling since 5 months
Back ache since 5 months
Burning micturition since 5 months
Tingling sensation in the lower limb since 4 months
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 years ago then he developed swollen ankle and feet, increased frequency of urination during night and shortness of breath and then went to near by hospital, got himself tested and was diagnosed with CKD. He is under medication (sodium bicarbonate 500 mg).
Patient developed back pain 5 months back which is squeezing type and non radiating which aggravated on lying and relieved on medication. He also developed right knee pain which is localised to the knee and also experiencing restriction of movement. No h/o trauma.
Patient also experiences burning micturition which is intermittent in nature associated with decrease frequency of urine not associated with dribbling of urine and blood in urine. Patient says that the it is relieved by consumption of toddy.
Patient is experiencing tingling sensation in both the lower limb since 4 months.
PAST HISTORY:
N/K/C/O DM, HTN, Asthma, TB, Epilepsy
H/O CKD since 10 years
H/O of rectal surgery 15 years back (can be a rectal prolapse)
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Diet is vegetarian
Appetite is normal
Sleep is adequate
Bowel and bladder - decreased frequency of urine
No known allergies to pollen, dust
Occasional alcoholic 10 years back
Tobacco consumption 10 years back
Occasionally consumes toddy
DRUG HISTORY:
Sodium bicarbonate 500 mg
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Thin built and malnourished.
There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
Vitals ---
BP: 120/80 mmHg
PR: 81 bpm
Temp: 97.4
RR: 17 cpm
GRBS: 20 mg%
SYSTEMIC EXAMINATION:
CVS: S1, S2 heard, no murmurs
RESP: NVBS, BAE
PER ABDOMEN: soft, non tender
CNS: NFND
INVESTIGATIONS:
1) T. NODOSIS 500 mg PO/OD
2) T. ULTRACET PO/OD
3) T. PAN 40 mg PO/OD
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