58 yr old male with neck pain and B/L knee pain

This is a paper based log book (with a corresponding E log version online) to discuss our patients de-identified health data, shared after taking his/her/guardian’s signed informed consent (check out the multilingual informed consent form template in the subsequent pages ahead). Here we discuss our individual patient’s problems through series of inputs from available local and global online community of learners and teachers with an aim to solve these patient’s clinical problems with collective current best evidence based inputs. This log book also reflects my patient- centered learning Portfolio, also available as an online learning portfolio and your valuable peer review inputs will enable me to learn further as to help our patients better.

A 58 yr old male farmer by occupation came with cheif complaints of 
Neck pain since 2-3 weeks
B/L knee pain since 3 months
Hopi
Pt was apparently normal 8 months back then he had c/o  chest pain SOB grade 3 then he consulted a private hospital where angioplasty was done he is put on medication since then using regularly
c/o neck pain since 2-3 months
c/o b/l knee pain since 3 months
c/o tingling and burning sensation of both feet since 1 yr 
No c/o reduced urine output,pedal edema,burning micrurition,pain abdomen,SOB,chest pain,orthopnea,PND,giddiness
Past history
k/c/o DM type 2 since 1.5 yrs for this he is using medication T.GLIMI M1 po/OD
k/c/o HTN since 3 yrs -Tab TELMA 40mg po/OD
k/c/o PTCA for this he is using medication -unknown
N/k/c/o TB, epilepsy,CVAthyroid disorder,bronchial asthma
Personal history
Diet:mixed
Appetite:normal
Bowel and bladder:regular
Sleep:adequate
Addictions:Alcohol 1quarter/day since 30 yrs stopped 8 months back and smoking stopped since 4 yrs 
Family history:not significant

General examination:
Pt is c/c/c moderately built and nourished
Pallor +
No cyanosis,clubbing,lymphadenopathy,pedal edema
Vitals:
BP:130/70mmhg
PR:96bpm
RR:18cpm
SPO2:99
GRBS:168
Systemic examination
CVS :sS1S2 heard,no murmurs
RS:BAE,no added breath sounds,NVBS
P/A:soft,non tender
CNS:NFND



Chest x ray
ECG




2D ECHO







Investigations:
Hb:10.8
Tc:5500
PTC:2.46lakhs/cc
Lft
Total bilirubin:0.56
DB:0.21
SGOT:17
SGPT:28
Alkaline phosphate:187
TP:6.3
A/G ratio:1.80
Rft
Urea:48
Creat:1.4
RBS:186




Provisional diagnosis: cervical spondylosis with osteoarthritis knee
Treatment:
1.Tab.ULTRACET PO/TID
2.Tab.SHELCAL 500mg PO/OD
3.Tab.GLIMI M1 PO/OD at 8am
4.Tab TELMA 40mg PO/OD











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