This is a case of an 82 year old man with pain in the neck, lower back, right knee and tingling sensation in his right arm

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This is a case of an 82 year old man with pain in the neck, lower back, right knee and tingling sensation in his right arm.

History of Presenting Illness:

Patient was apparently asymptomatic 10 years ago until he developed shortness of breath of grade 2. It has been occurring intermittently over the past 10 years. No history of Orthopnea or pnd

Until 5 years ago he says he had a relatively normal life and ran his own barber business for over 60 years. About 6 years ago, he started experiencing trembling and involuntary shaking of his hands and was not able to continue his business so he stopped working and started staying at home. 

2 years ago he developed pain in the right side of his neck which was radiating towards his right arm. He also developed pain in his right knee and left lower back.

Associated with morning stiffness and reduced range of movements. Pain increases on walking, climbing stairs and he is unable to sit on the floor. He has not been able to turn his head properly to the left since then. He also is unable to flex and extend his wrists

He has sought out treatment for these problems in his hometown but said they haven’t worked out so well for him.

He also has been experiencing episodic ringing sensation in his left ear since the past 2 years, at least twice in a week. 

He has been experiencing giddiness too, he was not able to recall since how long but he thinks it might have been occurring since his neck,knee and lower back pains have started.

1.5 years ago he had an episode of lightheadedness and profuse sweating and chest pain. The episode subsided after 15 mins after sitting down and eating something according to the attender.

4 months back, he had another episode of chest pain radiating to his left arm, associated with shortness of breath, profuse sweating. It was not associated with nausea, vomiting, palpations. He was taken to the hospital and was given antiplatelets, anticoagulants and statins and was discharged after 8 days of conservative management.

He hasn’t been able to walk properly, sit or do his daily activities since then.

Daily Routine:

Patient wakes up at 5 AM and drinks 2 glasses of hot water. Then he freshens up and drinks tea. Prior to his heart attack, he used to go for a morning walk, but now he remains at home. He eats breakfast at 8 Am and after that he doesnt do much other than lying down. He eats lunch at 3 pm and then he takes rest. If he feels like it, he watches TV. He eats dinner at 9 pm. The patient says it takes him a long time to fall asleep and his bedtime is usually after 12 AM

Past history:

He was diagnosed with hypertension 20 years ago and has been using medication since then.

Patient used to smoke beedi from the age of 20 to 50 years. He cannot recall how many he used to smoke in a day but claims he smoked atleast a few bundles.

He used drink atleast half litre of toddy a day until 30 years ago. 

Personal history:

Appetite normal

Diet mixed

Has been experiencing sleep distrbances and has used sleeping pills for years. Has stopped since 4 months

Bowel normal

Bladdder: experiencing decreased frequency of urination since 5-6 days. Flow has decreased

General examination

Patient is conscious, coherent and cooperative. Well oriented to time place and person.

Pallor: absent

Icterus: absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

Vitals:

BP 122/64 mmhg

Heart rate 70 bpm

Resp Rate 18 /min 

GRBS: 98 mg/dl

 

 

 

CVS

Inspection : 

Precordium :

 No precordial bulges.

No engorged veins.

No scar/sinus.

JVP: https://youtu.be/EkoZDToSxVA

PALPATION :

Apex beat appears to be in 5th intracostal space half an inch medial to midclavicular line

 

AUSCULTATION :

S1 ,S2 heard.

RESPIRATORY SYSTEM- 

Patient examined in sitting position

Inspection:-

Oral cavity, nose and nasopharyngeal appears normal

Chest appears bilaterally symmetrical and elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea appears central & Nipples are in 4th Intercoastal space

No dilated veins, scars, sinuses, visible pulsations. 

Palpation:-

All inspiratory findings confirmed

Trachea is central

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

MEASUREMENTS-

AP diameter-                 10 inches

Transverse diameter-    12 inches

AP/T ratio - 6/5

Respiratory movement's:- equal on both sides

Tactile vocal fremitus- equal on both sides

Percussion:-

                                       Right                     left

Supraclavicular- Resonant (R)                 (R) 

Infraclavicular-              (R)                        (R) 

Mammary-                     (R)                      (R)

Axillary-                          (R)                        (R) 

Infra axillary-                (R)                       (R) 

Suprascapular-             (R)                        (R) 

Interscapular-               (R)                        (R) 

Infrascapular-               (R)                         (R) 

Auscultation:-

Auscultation:-

                                      Right                     Left

Supraclavicular- Normal vesicular        (NVBS)

                        Breath sounds (NVBS) 

Infraclavicular-          (NVBS)                 Wheeze

Mammary-                 (NVBS)                 (NVBS)

Axillary-                      (NVBS)                 (NVBS)

Infra axillary-              (NVBS)                   (NVBS)

                                                          

Suprascapular-          (NVBS)                (NVBS)

Interscapular-            (NVBS)                (NVBS)

Infrascapular-          (NVBS)        (NVBS)

  

 

Abdominal Examination :

P/A soft,non tender

No organomegaly.

CENTRAL NERVOUS SYSTEM :

Motor and Sensory functions intact,

No evidence of any focal neurological deficits.

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

Coronary artery disease 

Cervical spondylosis

Lumbar spondylosis

Osteoarthritis of knee

Theme images by Michael Elkan

BHARGAVI KANTIPUDI ROLL NO 21

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