61 y/o man with SOB and involuntary movements of both upper limbs
61 yr old male with SOB and involuntary movements of both upper limbs
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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.
5 September 2022
Manvi Sharma
Roll no 88 (2k18 batch)
Case -
A 61 y/o male,who is a mason,a resident of Ramanapet came to the OPD with chief complaint of fever since 15 days and SOB since 10 days.
History of presenting illness-
Patient was apparently alright 3 yrs back then he developed b/l involuntary movements which are asymmetrical(more on right side) and of low amplitude,frequency and range.
He also mentioned he has observed slowing of movement and ??decrease in pitch of his voice since 1-2 yrs and stopped going to work, rather occasionally ( he even built his daughters house 1 yr back ), he was prescribed medications ( December 2021 ) for his involuntary movements which resulted in vain after using for 5 months
In April 2022, after his second sons marriage he apparently slept in an abnormal posture with his elbow flexed and waking up next day he wasn’t able to lift his left upper limb over the head and has been that way till now
2 months back he went to Karnataka for his involuntary movements being said herbal medication is the remedy and on not subsiding ,stopped using after 2 weeks.
15 days back he developed fever which is of high grade, intermittent in nature and not associated with chills and rigors. He was treated by the local doctor and the fever subsided in 3 days.
H/o dry cough since 10 days which is more at night on lying down.
H/o generalized weakness and decreased appetite since 10 days.
H/o SOB since 10 days.( class 2)
H/o burning sensation in the chest during night which is relieved on taking food since 10 days.
He went to private hospital yesterday afternoon where he was diagnosed to have pneumonia.
Past history-
He is not a k/c/o diabetes,hypertension, tuberculosis, asthma, epilepsy, leprosy, CAD, CVA
Personal history-
Diet -vegetarian
Appetite -decreased since 15 days
Sleep -decreased
B&B movements-regular
Addictions - started consuming alcohol 2 years back(after demise of his wife) and then stopped consuming since 1 year(due to the fear of alcohol affecting his health).
Family history-
No significant family history
General physical examination -
Patient is conscious,coherent and cooperative,well oriented to time place and person.
He is moderately built and nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy - absent
Clubbing - absent
Raised JVP
Vitals- (9-9-22)
Temp- Afebrile
PR - 92 bpm
RR- 19
BP - 110/70 mm Hg
Systemic examination-
CVS - S1, S2 heard , no murmurs
Apex beat localised at 5th ICS
RESPIRATORY SYSTEM-
Position of trachea is central
Shape of chest - cylindrical
BAE present
Breath sounds - Crepts heards at rt infra clavicular, mammary and infra mammary regions and lt mid axillary and infra scapular regions
ABDOMINAL SYSTEM- soft , non tender and mild hepatosplenomegaly
CNS -
Oriented to time, place and person
Able to recall events but there is delay in response
Speech is normal
No cranial nerve deficits
No loss of power
Tone - more increased on right upper limb
??Cog wheel rigidity
Hyper reflexia of biceps, triceps, supinator
2+ for knee reflex
Absent b/l ankle reflex
B/L plantar withdrawal +
Palmomental reflex +
Tremors in both upper limbs &/ hands which is coarse and static
Gait
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