A 75 year old male came to OPD with swelling and pain in left lower limb

Hi, I am Sravya, 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have 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. 

CHIEF COMPLAINTS
       Swelling and pain in left ankle since 1 week

HISTORY OF PRESENT ILLNESS 
     The patient was apparently assymptomatic 7 days back.The he developed pain in the left ankle for which  he applied zandu balm  for  which he developed swelling  over the applied area . He has pain over that area which was gradual in onset , pricking type which was continuous and radiating from ankle to groin and was relieved on medication.
He also had fever that was relieved on medication.
He also has burning micturition since 1 week.
It was not associated with any weight loss.


PAST HISTORY
      No history of DM
      No history of HTN 
      No history of CAD , Asthma , epilepsy, TB 
      No past surgeries

FAMILY HISTORY 
       Insignificant 

PERSONAL HISTORY
       Married
       Farmer by occupation
       Mixed diet 
       Decreased appetite
       Adequate sleep 
       Normal bowel movement
       Burning micturition
       Alcoholic - Drinks everyday
       Smoker - 2 to 4 / day
       No known allergies 
       
 GENERAL EXAMINATION 
       Conscious and coherent and cooperative
       Moderately built
       Moderately nourished 
       No pallor
       No icterus
       No cyanosis, clubbing of fingers ,           lymphadenopathy, 
       Pedal oedema was present 
  
VITALS 
 Temperature - 97.5F
  Pulse rate - 74beats /minute
  Respiratory rate - 16cpm
  BP  -130/70 mm of Hg
  SpO2 - 94%
  GRBS -94mg% 

SYSTEMIC EXAMINATION
 CVS 
 No thrills 
 S1 S2 + 
 No cardiac murmurs

RESPIRATORY SYSTEM
Centrally located trachea 
Vesicular breath sounds 
No dyspnea
No wheezing 

ABDOMEN
Scaphoid shaped abdomen
 No tenderness
No palpable mass
 
CNS 
Conscious and coherent
Normal speech

INVESTIGATIONS 
ULTRASOUND 

TREATMENT 
Inj. Monocef iv BD
Inj. Metrogyl iv TID
Inj pan 40 BD
Tab limcee
Tab dolo 650

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