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77 Y Male with tremors

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



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 74 year old male who came with a chief complaint of


1. Involuntary movements in the B/L upper limbs and lower limbs since 1 year 

2. Abdominal discomfort and tightness since 2 months 

3. Pain in B/L knee joints since 2 months 

HOPI : 

patient was apparently asymptomatic 1 year ago then he developed involuntary movements (tremors) in the B/lL Upper limb and lower limb , insidious in onset and gradually progressive to impair his day to day activities.

The movements are aggressive by work and not relieved with rest .abdominal discomfort since 2months , immediately after eating food burning sensation in the epigastric region 

N/h/o vomiting, loose stools ,pain abdomen

Pain in B/L knee joints difficulty in sitting down and getting up. 

No H/o any drug intake 

N/o any similar complaints in the past 


Past history:

N/k/c/o HTN / Dm / Tb /asthma/epilepsy 


Personal history:

He was a tailor for 30 years but has now retired. 

He lives a solitary life as his wife has passed away and has no children.

Diet: Vegetarian

Appetite: decreased since 1 month

Sleep: normal

Bowel and bladder: regular

Habits: none


 Family history:

insignificant


General Examination:

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

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema


Vitals : 

BP- 150/80 mmhg 

PR - 102 bpm 

RR - 18 CPM

Temp -96.2 F 

GRBS -108 

SPO2- 98 











CNS EXAMINATION: 


HIGHER MENTAL FUNCTIONS- 


Normal

Memory intact


CRANIAL NERVES :Normal


SENSORY EXAMINATION


Normal sensations felt in all dermatomes


MOTOR EXAMINATION


                        RT.  LT 


POWER -  UL 5/5  5/5


                  L L 5/5  5/5


TONE. -   UL     N   N


                LL.     N   N

REFLEXES 

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




CVS:


Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 




Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 




Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 




Respiratory system:

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 



Per Abdomen:

Shape is scaphoid

Abdomen is soft and non tender with no signs of organomegaly

Bowel sounds are heard


INVESTIGATIONS

HEMOGRAM

HB 12.2

TLC: 10200

Plt:3.25









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