62M with complaints of HTN, Joint pain and Diminision of vision in left eye
This is the case of a 62-year-old male, resident of West Bengal, and Government official by occupation (currently retired). The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.
This case report aims to record the patient's journey.
CHIEF COMPLAINTS:-
- HTN since 25 years.
- Knee pain on both legs since 2 years.
- Diminishion of vision in left eye since 1 year.
History of present illness:-
The patient is apparently asymptomatic 25 years back.
Upon regular doctor checkup, the patient was diagnosed with Hypertension. He reports to be following a sedentary lifestyle. His hypertention was in control with the help of medications prescribed by the local doctor throughout his work life. After retirement (in the year 2021), the patient reports to have had recurrences of headache and being irritable. Upon consultation with the local doctor, he was prescribed medications (which are listed in the report section).
In the year of 2021, the patient also complains of knee pain on both legs. The pain is insidious on onset and gradually progressive. The patient noticed the pain on the right knee first after it gradually progressed to the left knee. The pain was of dragging type. It is continuous in its presence. The pain would increase when the patient endulges in physical exercise or extensive walking and would relieve upon taking pain medications.
Last year, the patient complains of Diminision of vision in the left eye. The patient also complains of swelling on the left lateral aspect of the thigh. The swelling is sudden in onset and intermittent in its presence. There is burning sensation. There is no tenderness and the patient is able to perform physical activities inspite of the swelling. The swelling reduces by itself.
Daily schedule of the patient:-
In the patient's words:-
"I wake up at 7 in the morning, wash my hands and do exercise until about ten o'clock, drink water after exercise, then drink tea. After drinking tea, I help my wife in the kitchen. I eat bread and vegetables at 11:30 for cooking, then take medicine, exercise my wife's legs, and take a steam bath myself. Then I do household chores, market, etc., return home, rest for a while, take a bath. By five o'clock I water some plants in the roof garden. After watering, wash hands, wear newspaper, eat tea at seven o'clock, then watch TV and exercise my legs. After exercise, exercise my wife's legs at ten o'clock. I go to eat at 10:45, watch TV for a while and go to bed by 12:30 to 12:30. This is my daily routine."
History of past illness:-
The patient does not have any history of TB, DM, Epilepsy and asthma.
The patient has a history of HTN since 25 years.
Family history:-
The patient's father, mother, 2 elder brothers and 1 elder sister is reported to be suffering from HTN.
The patient's mother also has a history of piles.
Personal history:-
Water intake:- 1-1.5L
Appetite:- normal
Diet:- mixed (does not consume mutton and egg)
Bowel movement:- Normal
The patient has a history of piles from his student life (approximately in the year 1972) till the year he was married. This was resolved upon medication.
Bladder movement:- Normal
Alcohol:- No consumption
Smoking:- No consumption
Allergies:- No known allergies
Exercise status:-
GENERAL EXAMINATION:-
The patient was cooperative, conscious, coherent and the examination was done in a well lit and well ventilated room.
Pallor:- Slight pallor observed
Icterus:- none
Clubbling:- present
Cyanosis:- none
Lymphadenopathy:- none
Pedal edema:- pitting type of edema observed.
CLINICAL PICTURES:-
RADIOLOGY REPORT:-
REPORTS:-
MEDICATION:-
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