65 year old male

65 year old male from beemanapally


Date of admission 21/7/23

65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year. 

History of present illness:
 
Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which
Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking.

Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area.

Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep.
 
Past illness:
Diabetes since 15 years.
Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness.

History of Trauma
4 years back, then he had a fall while taking his cattle to the field due to which the patient experienced severe pain in the right hip and was unable to walk. 
Right hemiarthroplasty was done immediately. 
Since 1 yr the patient gradually developed backache and dragging type of pain in b/l lower limbs.
 He had difficulty in bending, difficulty in getting up from sitting position, joint stiffness+.

Drug history 
Insulin injections twice daily

Personal history 
Diet mixed 
Sleep is adequate 
Appetite decreased
Bowel and Bladder: normal
No Allergies 
Addiction: alcohol occasionally once in few weeks

Daily routine
The patient wakes up at 5 am and gets ready.
He generally prefers to have roti and curries for his breakfast.

After that he sleeps for few hours.
His lunch items includes rice and vegetables, mostly around 1pm.
Then he goes outside for a walk in the evening and is back by 8pm for dinner.

Patient is an agricultural labourer but has left his job since he was diagnosed with diabetes that is 15 years back.

General examination

Patient is conscious, coherent and cooperative and well oriented to time place and person.

No pallor, icterus, cynosis, clubbing,edema, lymphedenopathy 

Vitals

Pulse rate-68 bpm
Blood pressure- 130/80mm Hg
Respiratory rate- 16cpm
CVS- S1S2 +, no murmurs
RS- BLAE +, NVBS heard









Investigations

Ultrasound report

2D ECHO

 



Treatment
Biphasic insulin
Multi vitamin tablets
Pantoprazole 40 mg

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