75/M ; GIDDINESS
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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.
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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
This is a case of 75/M who came ; c/o giddiness since 3 years
Patient was apparently asymptomatic 3 years back after which he developed giddiness ,which got worsened in the past 2 months .It is associated with neck pain and pain along both the shoulders,pt finds it difficult to raise arms above shoulder.
Pain is non-radiating ,not associated with headache or head trauma.
H/o of occasional tingling sensation along both the upper limbs.
H/o of pain in both the knees since 6 years a/w difficulty in walking and rising from sitting position .
H/o of burning sensation in both the lower limbs from knee till sole of foot.
No h/0 of ear pain , discharge , or tinnitus.
H/o of gait abnormality present : short stepping gait with reduced arm swing . Not associated with abnormal movements.
H/o of ?CVA used ECOSPIRIN -AV for 3 months.
H/o of pedal edema upto knee, pitting type
H/o of analgesic abuse from past 1 year.
No h/o of SOB, Chest pain , Palipitations.
K/c/o of HTN on telma 40mg once daily.
N/k/c/o of DM2,TB,asthma, epilepsy, thyroid disorders.
Personal history:
Diet: mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder: Constipation (once in couple of days)
No addictions and allergies
GENERAL EXAMINATION:
Vitals:
PR-88 bpm
RR- 20 cpm
Temp-98.5
Bp-100/60 mmhg
Spo2-98 RA
GRBS-105 mg/dl
No pallor,No icterus, cyanosis, clubbing, lymphadenopathy.
SYSTEMIC EXAMINATION ::
GIT
INSPECTION :
Abdomen - scaphoid
Umbilicus - inverted
Movements - all quadrants are equally moving with respiration
No scars and sinuses
No visible peristalsis
No engorged veins.
PALPATION:
No local rise in temperature and no tenderness in all quadrants
LIVER: no hepatomegly
SPLEEN- not enlarged
KIDNEYS - bimanual palpable kidneys
PERCUSSION :
no shifting dullness
AUSCULTATION :
Bowel sounds are heard and are normal
No bruit
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical with pectum excavatum
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Bilateral Airway entry - present
Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.
Palpation: all pulses felt , apex beat felt.
Percussion: heart borders normal.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
Central Nervous system:
Higher motor functions- Intact
Cranial nerve functions - Normal
Sensory system-Normal(fine and crude touch, proprioception,vibration)
Motor system. Right Left
Power- UL 4/5 4/5
LL 4/5 4/5
Neck Normal
Trunk muscles Normal
Tone- UL Normal Normal
LL Normal Normal
Reflexes-
Superficial reflexes - Intact
Plantar flexion extension
Deep tendon reflexes -
Biceps ++ ++
Triceps ++ ++
Supinator + +
Knee + +
Ankle + +
Cerebellum
Romberg: negative
Finger nose in coordination :absent
Dysdidokinesia : absent
Hallpike dx: negative.
INVESTIGATIONS:
Radio-images:
DIAGNOSIS: Cervical spondylosis , Osteoarthritis of knees , cholelithiasis
TREATMENT:1.T. MVT
2.T. LIMCEE
3.T.SHELCAL
4.T.ULTRACET
5.URSODEL
6.TELMA 40 .
