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I've 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.
Name:- Kattekola Sathwik
Roll No :- 75
Case Report :-
60/F farmer came with complaints of
Tingling sensation of both lower limbs since 3 years
complaints of bilateral knee pain since 5 years
Complaints of burning micturition since 3 years
patient was apparently asymptomatic 10 years ago then she developed tingling sensations,numbness and burning sensations of both lower limbs since 10 years(slrt-negative)
Complaints of bilateral knee pains since 5 years which is insidious in onset gradually progressive , crepitus present no morning stiffness, tenderness,swelling
aggravating with prolonged standing and on activity and relieving on rest and generalised body pains
Complaints of burning micturition since 3 years which is not associated with fever with chills,frequency,urgency,hesitancy,
poor stream of urine,dribbling of urine
(Aggravates after eating non veg)
No h/o trauma
No h/o polyuria,polydypsia,polyphagia
No h/o chest pain,sob,palpitations
No c/o fever,pain abdomen,vomiting,loose stools,cough,cold
Past History
H/o renal calculi 7 years ago
H/o ?cerebral malaria 10 years ago
K/c/o DM since 20 years(on medication of tab.metformin 500mg po/bd)
Not a k/c/o Tb,epilepsy,bronchial asthma,cva,cad,HTN
Personal History
She takes mixed diet
sleep normal
stools regular
micturation- burning micturition since 3 yrs
no addictions
no significant family history
On examination
no pallor icterus cyanosis clubbing pedal edema lymphadenopathy
BP:-130/70 mmhg
PR 80 bpm
GRBS:-346mg/dl
CVS: s1s2 heard
RS :- b/l air entry present ,NVBS
PA: soft,non tender, no organomegaly
cns:hmf intact
Sensory Examination
Investigation
USG abdomen and pelvis
Chest X ray PA
In view of Right hydronephrosis Urology referral was done on 25.03.2023
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