70 Y MALE WITH B/L KNEE PAINS AND TINGLING SENSATIONS
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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 diagnosis and treatment plan.
This is a case of a 70 year old male who came with complaints of
1.Pain in both knees since 1 year
2.Tingling sensations of both upper and lower limbs since 1 year
HISTORY OF PRESENTING ILLNESS:
Pt was apparently asymptomatic 1 year back and then developed pain in both knees ,insidious in onset , gradually progressive,associated with pain during walking and difficulty in sitting on floor and getting up from squatting position
H/o tingling sensations of both upper and lower limbs since 1 year,insidious in onset,gradually progressive
No H/o polyuria ,polydipsia,polyphagia
No H/o pedal edema ,facial puffiness
No H/o burning micturition
No H/o decreased urine output
No H/o sob ,chest pain
No H/o fever, cough.
PAST HISTORY:
K/c/o Type 2DM Since 6 years (on tab Glimi M1 once daily
N/k/c/o HTN,TB ,thyroid disorder,asthma.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder: normal
Addiction:H/o bidi smoking (3-4 bidis/day)
H/o alcohol consumption 90 ml whiskey once or twice a month since 20 years
DAILY ROUTINE:
The patient wakes up at around 6 am in the morning and completes his daily morning activities and has his breakfast around 8 am.
He is a farmer but he stopped going to work since 3 years because of knee pains and stays at home the whole day.
He has his lunch at 2 o'clock in the afternoon and dinner at 8 pm , after that he goes to sleep. He is having a sedentary lifestyle since 3 years.
GENERAL EXAMINATION:
Vitals :-
Bp:- 120/90 mm hg
RR:- 18CPM
PR:- 76 BPM
GRBS:- 90 mg/dl
No pallor,icterus, cyanosis, clubbing, lymphadenopathy , edema.
Local examination-
Knee joint :
Joint line tenderness +
B/L crepitus +nt
Systemic Examination-
Cvs-S1,S2 +
No Murmurs
Rs-BAE+
NVBS Heard
P/A-soft
Non tender
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
RT LT
FINE TOUCH N N
CRUDE TOUCH N N
PAIN DECREASED OVER TOES OF BOTH LOWER LIMBS
JOINT POSITION N N
TACTILE LOCALISATION N N
MOTOR EXAMINATION
RT. LT
POWER - UL 5/5 5/5
L L 5/5 5/5
TONE. - UL N N
LL. N N
REFLEXES RT LT
biceps 2+. 2+
Triceps 2+. 2+
Supinator 1+. 1+
Knee 2+. 2+
Ankle. 1+. 1+
Plantar B/L flexed
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
INVESTIGATIONS:
HEMOGRAM:
Hb - 14.3 gm/dl.
TLC -7200 cells/cumm
N/L/E/M- 55/36/3/6
PLC-1.63 lakhs /cumm
RDW -CV - 15.6%
RBS-85mg/dl.
FBS 80 mg/dl.
Hba1c - 6.6%
Blood Urea- 20mg/dl.
Serum creatinine- 0.7mg/dl
CUE:
ALBUMIN +
PUS CELLS 3-6
EPITHELIAL CELLS 2-3
SERUM ELECTROLYTE
Sodium 140 meq/l
Potassium 3.8meq/l
Chloride 106 meq/l
Calcium ionized 1.13 mmol/l
ECG:
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