63 YEAR OLD MALE WITH BACK PAIN UNDER EVALUATION.

SUDHAMSHI REDDY M

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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 diagnosis . 

63 year old male agricultural worker by occupation came with chief complaints of

• B/L knee joint pain since 1 year
• Back pain since 1 year
• Neck pain since 4-6months

HISTORY OF PRESENTING ILLNESS: 

Patient was apparently normal 1 year back he then had 

- Pain in both the knee joints- insidious in onset, gradually

  progressive. Early morning stiffness present.

  Pain aggravated on walking long distances, relieved on 

  resting.

- C/O lower back pain since 1 year, insidious in onset, 

   gradual in progression, aggravated on working by 

   bending forward or lifting weights. 

   Non radiating

   Tingling sensation present.

- C/O neck pain since 4-6 months, radiating towards both 

   shoulders. 

   No tingling sensation.

-C/O dull dragging type of pain in the centre of chest 

  non radiating , aggravated on exertion and relieved by 

  rest .

  Not associated with SOB, palpitations, giddiness, 

  sweating 

-C/O pain and tingling sensation in both feet.

-H/O an attack of giddiness 3 days back associated with 

 loss of consciousness , regained consciousness within 

 1minute and was normal without any confusion.

-No h/o fever, pain abdomen, burning micturition .

PAST HISTORY:

No similar complaints in the past

Not a k/c/o DM,HTN ,TB ,Asthma ,CVA, CAD ,Epilepsy, Thyroid disorders.

Surgical history-

Operated for Right eye SIMC 10 yrs back

PERSONAL HISTORY:

Diet mixed

Appetite normal

Sleep normal

Bowel and Bladder Regular

Occasional alcoholic drinks once in 10-15 days since 10 years.

Non smoker.

GENERAL EXAMINATION:

O/E 

Patient is conscious coherent cooperative

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

VITALS:

Afebrile on touch

PR : 88bpm

RR : 18cpm

BP : 140/90 mm hg

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM: 

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally with respiration on both sides

Tactile Vocal fremitus - appreciated 

PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.

CARDIOVASCULAR SYSTEM:

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

PER ABDOMEN: 

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

 Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM EXAMINATION:

Higher mental functions - intact 

Straight Leg raising test: 

Patient complains of pain at 60 degrees in left lower limb and at 45 degrees in right lower limb.

INVESTIGATIONS:

CXR

X-RAY C SPINE: 

Lateral view-

AP view-

X-RAY B/L KNEE JOINT:

 

Lateral view-

AP view-

X-RAY LS SPINE

AP view-

LATERAL view-

ECG-

2D ECHO- 

USG ABDOMEN- 

PROVISIONAL DIAGNOSIS:

 Back pain under evaluation 

 ? B/L knee osteoarthritis 

 Cervical spondylosis.

TREATMENT:

1. Tab ULTRACET PO/BD 

2. Tab PAN 40mg PO/OD

REFERRAL NOTES:

 Orthopaedic referral