65 year old male with pedal edema and burning micturition
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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.
My case was a 65 year old male who is farmer by occupation came with the
CHEIF COMPLAINTS :
Pedal edema since 1 month ,constipation since 1 month,
Burning micturition and decreased urine output since 15 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 years back one fine day when he was tending his buffalos they were trying to run away so he ran after them then he fell down on his back while running he got injured and had pain at the neck region for that he started taking pain killer one pill a day at night before sleep.
6 months later again a similar incident of him running after his buffalos and same as the last time he fell on his back since then he is not able to walk properly describes his walking movement as swaying side to side and losing his balance and falling to the floor
And the 6 months later he developed lower back pain which is radiating towards both lower limbs and associated with tingling sensation which aggrevates on walking and relieves on rest
.and also he developed Bilateral knee pain which is of dull aching type insidious in onset and progressive in nature and Bilateral swelling of knee present .history of icterus (kamerlu) which has subsided by taking some herbal medicine (not known)And then since 1 month he developed bilateral pedal edema which is initially at ankle and then progressed to knee which is of pitting type he also has sob on exertion. history of not passing the stool since 1month only if he takes tonic he is passing stools the next day .history of burning micturition since 15 days.no decrease in urinary output,no urgency of urine.
PAST HISTORY
not a known case of Diabetes, hypertension, epilepsy, asthma, tuberculosis.
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
DIET :mixed
APPETITE:NORMAL
SLEEP :ADEQUATE
BOWEL AND BLADDER :CONSTIPATION PRESENT
ADDICTIONS :He had habit of drinking toddy since child hood and he had habits of smoking since 30 years and habit of drinking alcohol (whisky)since 28 years.
GENERAL EXAMINATION:
Patient is conscious ,coherent and cooperative
Moderately built and moderately nourished
Well oriented to time place and person .
No pallor ,icterus ,cyanosis and lymphadenopathy
He has Bilateral pedal edema which is of pitting type which is initially at ankle and then progressed to knee.
VITALS:
BP:90/60mmhg
PR:78 bpm
RR:16 cpm
TEMP:afebrile.
SYSTEMIC EXAMINATION:
EXAMINATION OF CNS:
He is a right handed person
HIGER MENTAL FUNCTIONS.....
conscious ,oriented to time place and person.
Speech:normal
Behavior:normal
Memory :normal
Intelligence:normal
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION....
1ST :NORMAL
2nd: visual field and colour vision normal.
3rd ,4th,6th: pupillary reflexes present .
EOM full range of movements present.
Colour vision normal.
5th :sensory Intact and motor intact .
7th :normal
8th :normal
9th and 10th : no abnormalites noted and palatial movements present and equal.
11 and 12th: normal .
MOTOR EXAMINATION: right. Left
UL. LL. UL. LL
BULK. NORMAL. NORMAL
TONE. NORMAL. NORMAL
POWER
Power: right left
Shoulder:
flexion : 4/5 ?
Extension 5/5 ?
Abduction :
Supraspinatus:4/5. ?
Deltoid:4/5. 2/5
Serratusanterior :2/5. 2/5
Trapezius:4/5. 2/5
Adduction 5/5 ?
Internal rotation 5/5 ?
External rotation 5/5 ?
Elbow:
Flexion:5/5. 5/5.
Extension:5/5. 5/5.
Wrist:5/5. 5/5.
Flexion:5/5. 5/5.
Extension:5/5. 5/5.
Abduction :5/5. 5/5.
adduction:5/5. 5/5
Hip
Flexion:5/5. ?
Extension5/5. ?
Abduction:4/5. ?
Adduction4/5. ?
Internal rotation:5/5. ?
External rotation5/5. ?
Knee
Flexion :5/5 5/5
Extension5/5 5/5
Ankle
Plantarflexion:5/5. ?
Dorsiflexion5/5. ?
Toe
Movements:5/5
Impression : left upper limb and lower limb cannot move against gravity
SUPERFICIAL REFLEXES :
CORNEAL. PRESENT. PRESENT
CONJUNCTIVAL. PRESENT. PRESENT
ABDOMINAL. PRESENT
PLANTAR MUTE. WITHDRAwal
DEEP TENDON REFLEXES:
BICEPS. 3. 3. 3. 3
TRICEPS. 3. 3. 3. 3
SUPINATOR. 3. 3. 3. 3
KNEE. 3. 3. 3. 3
ANKLE. 1. 1. 1. 1
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch present
Pain present
DORSAL COLUMN SENSATION::
Fine touch present
Vibration present
Proprioception present
CORTICAL SENSATION:
Two point discrimination
Tactile localisation present
CEREBELLAR EXAMINATION:
Finger nose test not able to perform
Knee heel test able to perform
Dysdiadokinesia: able to perform.
Rombergs test : Patient swaying towards back.(rombergs test positive )
SIGNS OF MENINGEAL IRRITATION:ABSENT
GAIT: WIDE BASED WHILE WALKING UNSTEADY WITH A TENDENCY TO FALL .
EXAMINATION OF RESPIRATORY SYSTEM:
Normal vesicular breath sounds present
Bilateral air entry present
Symmetrical movement of the chest on both sides .
ABDOMINAL EXAMINATION :
Abdomen is scaphoid, no scars present, no sinuses present,no engorged veins,no visible pulsation,all quadrants are moving equally with respiration and on Palpation abdomen is soft and non tender no lump ,no rigidity and no guardity
EXAMINATION OF CVS:
S1AND S2 HEARD ,NO MURMURS ARE HEARD
Clinical images:
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