88 YEAR OLD MALE WITH CHIEF COMPLAINTS OF DECREASED HEARING IN LEFT EAR AND HEAVINESS.

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've 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 a diagnosis and treatment plan.

CASE :-

This is a case of 88 years old male admitted in ward with chief complaints of -

1) Partial hearing loss in left ear since 3 months.

2) Heaviness in the left ear since 15days. 

3) Knee pain and pain in distal phallenges since 4 years. 

HISTORY OF PRESENTING ILLNESS :-

-The patient was asymptomatic 4 years back. 

-He then developed knee pain which was acute in onset gradual progressive in nature. Later pain in distal phallenges was also noted. Presently he is walking with the help of a stick as his motion is being dependent and restricted. 

- The patient has been feeling generalized weakness all throught the body since around 6 months.

- The patient then developed partial hearing loss in the left ear since 3 months which was acute on the onset and is gradual and progressive in nature. He is also experiencing aural fullness on the left side. 

HISTORY OF PAST ILLNESS -

- The patient had undergone abdominal surgery 20 yrs back (Omentoplasty ?)

- The patient underwent cataract surgery in left eye 1 year ago.

-No history of DM , HTN, TB, EPILESPY, ASTHAMA, CHD.

PERSONAL HISTORY - 

- Diet - mixed 

- Appetite - decreased since 15 days 

- Bowel and bladder - Normal

- No addiction.

FAMILY HISTORY - 

- No significant family history.

ALLERGIC HISTORY - 

-No allergic history.

GENERAL EXAMINATION 

- Patient is C/C/C

VITALS - 

- Temp - Afebrile 

- Pulse - 74 bpm

- BP - 125/80 mmHg 

- RR - 16cpm

- Pallor - no

- Icterus - no

- Cyanosis - no

- Clubbing - no

- Lymphadenopathy - no

CVS -

Cardiac sounds      :- S1 & S2 - Present

Cardiac murmurs   :- no

RESP. SYSTEM - 

Dyspnoea - no

Position of Trachea - Central

Breadth Sounds - Vesicular

ABDOMEN - 

Shape of abdomen - Distended 

Tenderness - no

Palpable Mass - no

Liver - Not Palpable

Bowel sounds - Yes

Operative scar present.

C.N.S

Level of consciousness : Consciousness: Conscious / Alert 

Speech - Normal

Signs of Meningeal irritation   a)Neck stuffiness - NO  b) Kernig's sign - NO

Cranial nerves - Normal

Sensory nerves - Normal

Motor system - 

- Power: 5/5 in both UL and LL

- Tone- normal 

- Bulk - decreased

- Reflexes - 

Biceps, Triceps Supinator Knee reflexes intact (++) 

No cerebellar signs noticed

INVESTIGATIONS -

XRAY - A P VIEW and LATERAL VIEW  OF KNEE JOINT.

X RAY - A P VIEW and  LATERAL VIEW OF C-SPINE.

X RAY C SPINE  - 

1) slight bending of c spine towards right side ( AP VIEW )

2) Spaces decreased ( LATERAL VIEW ) 

X RAY KNEE JOINT - 

1) Inflammation of knee joint seen.

COMPLETE BLOOD PICTURE

PROBABLE DIAGNOSIS -

Senile osteoarthritis ?

Presbycusis ( age related hearing loss) ?