75 year old female with b/l knee pain ,dry cough,neck pain

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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.  

75year old female, previously labourer by occupation 

Came with c/o

B/L knee since 3years 

Dry cough since 1 year 

Neck pain since 1 year 

Tingling and numbness since 6months 

Patient was apparently alright 3years ago then she started compiling of b/l knee pain ; no history of trauma 

which is aggravated on exertion 

relieved on rest 

Patient complaints of dry cough since 1 year; insidious in onset; gradually progressive in nature 

Mainly at night and early morning 

Aggravated on eating curd and tangy food 

No h/o cold ; cough with expectoration ; sob ; chestpain and palpitations 

Neck pain since 1 year ; no aggravating and relieving factors ;  no h/o headache ; nausea ; radiating of pain 

Tingling in numbness of left lower limb since 6months ; no lower back pain; non radiating pain ; no spinal tenderness .

SLRT negative 

K/c/o hypertension since 3 years is on tab. Telmisartan 40mg PO OD 

Past history- 

hysterectomy done 30years ago 

Personal history:- 

Diet -mixed

Appetite:- adequate 

Sleep:- adequate

Bowel and bladder movement-regular 

Addictions:- none 

General examination:- 

Patient is conscious, coherent, cooperative well oriented to time place and person moderately built moderately nourished

No pallor, icterus, cyanosis clubbing, generalized lymphadenopathy, bilateral pedal edema  

 

Systemic examination:-

 PA:

Inspection:

Round, large with no distention

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation: 

Soft, tenderness present in epigastric region

No signs of organomegally

Percussion: 

No fluid thrill, shifting dullness absent

Auscultation: 

Bowel sounds heard 2-3/ minute

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 

. 

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. 

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Vitals:- 

Bp:- 130/70 mmhg 

RR:- 18 cpm

PR:- 80bpm

Temp:- afebrile

Spo2:-99% at RA 

Investigations:- 

Provisional diagnosis:-

Acid peptic disease since 1 year ,grade 2 osteoporosis of bilateral knee since 3 years , cervical spondylosis and lumbar spondylosis,k/c/o htn since 3 years

Treatment:-

Tab   telmisartan 40 mg po/of 8am 

Tab pan 40 mg po/od 7am for 7 days 

Tab shelcal po/od 1/2 tab 6am .....1/2 tab 8pm for 7 days 

Tab ultracet po/od 1/2 tab 6am......1/2 tab 8pm for 7 days 

Tab neurokind LC po/hs 15 days