88 Y/O male with chief c/o Decreased hearing in left ear and Aural fullness

 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 a 88 year old Male admitted in the ward, with a complaints of 

  • Decreased hearing and fullness in left ear 
  • Pain in Knee and distal phalanx


 History Of Presenting illness:


 Patient was apparently asymptomatic 4 years ago, after which he devloped pain in Knee joint and Distal Phalanx which was insidious in onset, Gradually progressive , Dull aching type in nature, not radiating , aggregated on physical activity and relieved temporarily on rest and medication.

3 months ago, pt. had complaints of decreased hearing and fullness in ear, which was insidious in onset, Gradually progressive, no aggravating or relieving factors








History of Past illness:

  • H/o Abdominal surgery 20 years ago (omentoplasty?) Abdominal scar present 


  • H/o cataract surgery in left eye 1 year ago.
  • No h/o HTN, DM, Epilepsy, asthma, CAD




Personal History:

  • Diet- mixed
  • Apetite- decreased since 15 days
  • Seep- adequateo
  • Bowel and bladder: Normal
  • No Addictions




Family history:


 No Similar history 




Allergic history:


No known allergies






General physical examination-

Patient is C/C/C. 

Vitals 
PR: 74 bpm
BP - 124/80 mm Hg
RR - 16/min
Temp - Afebrile 

No Pallor, icterus , cyanosis , clubbing , lymphadenopathy ,edema








SYSTEMIC EXAMINATION

CVS 

Cardiac sounds :- S1 & S2 - Present
Cardiac murmurs :- NO 



RESP. SYSTEM

Dyspnoea : NO
Position of Trachea : Central
Breadth Sounds : Vesicular +



ABDOMEN
Shape of abdomen : flat
Tenderness : NO
Palpable Mass : NO
Liver : Not Palpable
Bowel sounds: Yes



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



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:-





























Probable Diagnosis:-



Senile Osteoarthritis?  
Age related hearing loss (Presbycusis?)

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