75 MALE WITH GIDDINESS

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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 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/o 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.

PAST HISTORY 

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:

Patient is conscious,coherent and cooperative 

Moderately built and noirished.

No pallor,No icterus, cyanosis, clubbing, lymphadenopathy

Vitals:

PR-88 bpm

RR- 20 cpm

Temp-98.5  

Bp-100/60 mmhg 

Spo2-98 RA 

GRBS-105 mg/dl.

 

SYSTEMIC EXAMINATION ::

Cvs-S1,S2 +

        No Murmurs

Rs-BAE+

    NVBS Heard

P/A-soft

    Non tender

CNS EXAMINATION

Higher motor functions- Normal 

Cranial nerve functions - Intact

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:

USG ABDOMEN:

 X RAYS

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 .