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 CASE OF 70 YR OLD MALE 

Greetings to one and all who are currently reading my blog.  This is Jasmisri,fifth semester medical student

This is an online E - log book to discuss our patients 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-centered online portfolio and your valuable inputs on the comment box.

.CASE:-

A 70 year old male shepherd 3 yrs back (Toddy seller 30yr back) by occupation from yadhagiri 

CHIEF COMPLAINTS

Pedal edema 20 days


HISTORY OF PRESENTING ILLNESSV

Patient was asymptomatic 35yrs back 

Bouts of cough  with sputum ( sputum is same as morning normal sputum)since 15  days (stopped after stopping of taking chutta)

Edema of legs ,face, hands relieved on applying ointment ? And after 2 days it appears again again he applies ointment

Constipation from so many days relieved only on medication

Left and right foot pain 

Left great toe pain

Right side back neck pain 

PAST HISTORY

35years(2007-2008) back he had a left leg fracture at popliteal fossa ( during rainy season he slipped and fell on his own leg due to his own weight leg has broken? )treated by kattu?(they didnot go to hospital)

Still for 2-3 years he continued his toddy collecting job then he stopped and for some days he worked as shepherd after some days  he stoped it too 

Blood in stool ?

He had episodes of dizziness (reason for his left side neck pain)

He went to chowtpalli hospital himself without telling to his son.In hospital he fell down (due to dizziness?) and he did vomiting 4-5 times then he was very weak.

 In the same hospital  he put on glucose and then he came to kims (with help of his son )on the same day evening. 

No significiant history of DM,TB,Epilepsy,HTN

PERSONAL HISTORY

Diet:Mixed,normal appetite 

Sleep: decreased sleep due to bouts of cough

Constipation relieved only on medication

Normal bladder movements

Adictions- Chutta since 40 yrs  4-5 chuttasper day stooped since 4-5 days

Alcohol intake he drinks when he wants to drink (90ml)

FAMILY HISTORY 

No significant family history

SURGICAL HISTORY

Left Eye operation 10 years ago due to decreased vision

GENERAL EXAMINATION

  • PALLOR
  • No ICTERUS
  • NO CYANOSIS
  • NO CLUBBING
  • NO KOILONYCHIA 
  • NO LYMPHADEONAPTHY
  • EDEMA














SYSTEMIC EXAMINATION:-

A. Cardiovascular system 
S1 S2 HEARD
NO MURMURS.

B. Respiratory system 
NVBS heard
BAE +
TRACHEA CENTRAL.

C. Per abdominal examination 
SOFT
Scaphoid
Mild tenderness on left hypochondrium

D.NEUROLOGICAL EXAMINATION

1. HIGHER MENTAL FUNCTIONS:
  • a. Consciousness – intact
  • b. Well Oriented to time, place and person
  • c. Speech and language – slurring.
  • d. Memory – immediate-retention and recall, recent and remote - intact
  • a. No Delusions, hallucinations
  • b. No Emotional lability
  • c. MMSE score
I. Orientation

1. date x, day x, month x, season(rainy) yearx (1)
2. floor x, hospital x. District (1), state , country (1)

II. Registration

Name three objects taking one second for each object. Ask him to repeat the same.
Repeat till he remembers (3)

III. Attention and Calculation

Serial 7’s 5 times (0)

IV. Recall

Recall the three objects (3)

V. Language

  • 1. Name 2 objects (1)
  • 2. Repeat a sentence (1)
  • 3. Follow a 3 stage command (3)
  • 4. Reading “close your eyes”(0) – not able to read
  • 5. Writing a sentence (0) – not able to write
  • 6. Copy a design (0)
2. CRANIAL NERVES
CRANIALNERVE

TEST RIGHT LEFT

I Sense of smell

i) Sanitizer + +
II i) Pupillary reflex Normal Cataract
surgery

3. MOTOR SYSTEM

TEST RIGHT LEFT

I – BULK
a. Inspection
b. Palpation
c. Measurements
Upper limb – 10cm above and below acromion
Lower limb 18 cm above and 10 cm below tibial
tubercle

Decreased
Normal
cms
cms

Decreased
Normal
cms
cms

II – TONE

a. Upper limbs-Hypertonia
b. Lower limbs-Hypertonia 

III – POWER

a. Neck muscles-Good
b. Upper limbs

i) Shoulder
Flexion-Extension
Abduction / adduction
ii) Elbow
Flexion-Extension
iii) Wrist
Dorsi flexion-Palmar flexion
Abduction-Adduction
iv) small muscles of hand
v) Hand grip

c. Lower limbs

i) Hip
Flexion-Extension
Abduction-Adduction
Lateral Rotation-Medial Rotation
ii) Knee
Flexion-Extension
iii) Ankle
Dorsi flexion-Plantar flexion
Inversion-Eversion
iv) Small muscles of foot
d. Trunk muscles
e. Beevor’s sign

Good
4/5
4/5
4/5
5/5
4/5
4/5
Good
Good

4/5
4/5
4/5
4/5
4/5

Weak
Absent

Good
4/5
4/5
4/5
4/5
4/5
4/5
Good
Good

4/5
4/5
4/5
4/5
4/5

Weak
Absent

IV – REFLEXES
A. SUPERFICIAL REFLEXES
1. Corneal
2. Conjunctival
3. Palatal Reflex
4. Plantar Reflex
B. DEEP TENDON REFLEXES
1. Jaw jerk
2. Biceps jerk
3. Triceps jerk
4. Supinator jerk
5. Finger flexion reflex
6. Knee jerk
7. Ankle jerk
8. Clonus
C. PRIMITIVE REFLEXES

Present
Present
Present
Flexor
?Present
-
Present
-
-
-
-
NT

Present
Present
Present
Extensor
Present
-
Present
-
-
-
-
NT

D. OTHERS

Hoffmans sign -Absent
Wartenbergs sign-Absent
Rossalimos sign-Absent


V – COORDINATION

TESTED ALONG WITH THE CEREBELLUM

Impaired

VI – GAIT 

Wide based gait

VII – INVOLUNTARY MOVEMENTS

A – Athetosis, Asterexis
B – Ballismus
C – Chorea
D – Dystonia
E – Essential tremors
F – Fasciculations
M - Myoclonus

No

4. SENSORY SYSTEM

TEST RIGHT LEFT
I – SPINOTHALAMIC
1. Crude touch
2. Pain
3. Temperature
II – POSTERIOR COLUMN
1. Fine touch
2. Vibration
3. Position sense

1. Tactile localisation
2. Stereognosis

Normal
Normal
Normal
Normal
Normal
Normal
Absent
Normal
Normal

Normal
Normal
Normal
Normal
Normal
Normal
Absent
Normal
Normal

5. CEREBELLAR SIGNS
1. Titubation - absent
2. Truncal ataxia/gait ataxia/ stance ataxia – present
3. Nystagmus – absent
4. Dysarthria - absent
5. Hypotonia - absent
6. Rebound phenomenon – absent
7. Intention tremor - absent
8. Pendular knee jerk – absent
9. Tandem Walking – couldn’t elicit due to giddiness
a. Upper Limbs – Finger Nose test, Finger Finger Nose test – impaired on left
side.
b. Lower Limbs – Heel Knee test, - impaired on left side
c. Dysdiadokokinesia – impaired

6. AUTONOMIC NERVOUS SYSTEM

Resting tachycardia- present (?Anxiety)
Abnormal sweating - no

7. SIGNS OF MENINGEAL IRRITATION

Neck stiffness present
Kernig’s sign - - x
Brudzinski’s sign - - x

8. EXAMINATION OF THE SPINE AND CRANIUM

SPINE – normal
CRANIUM – normal

9. PERIPHERAL NERVES

No Thickened nerves
No Trophic ulcers
No Wrist drop
No Foot drop

INVESTIGATIONS











15/09/22

























16/09/22


17/09/22




18/09/22


19/09/22











PROVISIONAL DIAGNOSIS:

SECONDARY ANEMIA UNDER EVALUATION,BLEEDING PER RECTUM
HEMORROIDS

TREATMENT:

15/09/22

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj LASIX 40mg IV/OD
Inj ZOFER 4mg IV
Syp CREMAFFIN 30ml/PO/OD
Two egg whites per day

16/09/22

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj LASIX 40mg IV/OD
Inj ZOFER 4mg IV/TID
Syp CREMAFFIN 30ml/PO/OD
Two egg whites per day

17/09/22

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj LASIX 40mg IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp CREMAFFIN 30ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day

18/09/22


S

Bleeding PR,Dizziness,
No fever spikes,stools passed

O

Pt is conscious, coherent cooperative

Bp:-120/70mmHg
Pr:-76 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to maligancy?fissure?

P

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp CREMAFFIN 30ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day

19/09/22


S

Dizziness
No fever spikes, no stools passed

O

Pt is conscious, coherent cooperative

Bp:-120/70mmHg
Pr:-78 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to maligancy?fissure?

P

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp CREMAFFIN 30ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day

20/09/22


S

Giddiness
No fever spikes, no stools 

O

Pt is conscious, coherent cooperative

Bp:-110/70mmHg
Pr:-88 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to hemorroids?maligancy?fissure?

P


Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp CREMAFFIN 30ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring

21/09/22

S

Tinnitus in rt ear,giddiness
No fever spikes,stools passed

O

Pt is conscious, coherent cooperative

Bp:-120/70mmHg
Pr:-76 bpm
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to hemorroids?maligancy?fissure?

P

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp CREMAFFIN 30ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring


22/09/22
 

S

Tinnitus in rt ear,giddiness
No fever spikes,no stools

O
Pt is conscious, coherent cooperative

Temp-98.6°F
PR:82BPM.
Bp:120/70mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to hemorroids ,rectal prolapse

P

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring

23/09/22
 

S

Tinnitus in rt ear,giddiness
No fever spikes,stools passed

O
Pt is conscious, coherent cooperative

Temp-97°F
PR:78BPM.
Bp:110/70mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to fissure? hemorroids,rectal prolapse ,chronic constipation

P

Inj IRON SUCROSE 200mg in 100ml NS IV/OD
Inj ZOFER 4mg IV/TID
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM


24/09/22
 

S

Tinnitus in rt ear
No fever spikes

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:88BPM.
Bp:140/70mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse 

P  

Tab  LIVOGEN /PO/OD
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Ointment ANOBLISS for L/A
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD

25/09/22
 

S

Tinnitus in rt ear
No fever spikes
vertigo

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:86BPM.
Bp:110/70mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse,sensory ataxia

P  

Tab  LIVOGEN /PO/OD
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD

26/09/22
 

S

Tinnitus in rt ear
No fever spikes,stools passed
vertigo

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:92BPM.
Bp:120/90mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse,sensory ataxia

P  

Tab  LIVOGEN /PO/OD
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD

27/09/22
 

S

Tinnitus in rt ear
No fever spikes,stools passed
vertigo

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:92BPM.
Bp:120/90mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse

P  

Tab  LIVOGEN /PO/OD
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD

28/09/22
 

S


No fever spikes
vertigo

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:92BPM.
Bp:120/90mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse,superior cerebellar artery stroke?

P  

Tab  LIVOGEN /PO/OD
Tab PROMETHAZINE 10mg/PD/TID
Syp DUPHALAC BULK 20ml/PO/OD
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD


29/09/22
 

S


No fever spikes,stool passed
vertigo

O
Pt is conscious, coherent cooperative

Temp-afebrile
PR:92BPM.
Bp:120/90mm Hg
Cvs:-s1s2+
R/s:-BLAE +
P/A:- soft , non tender
CNS:- NAD

A

Severe anemia?, bleeding PR, 2° to  hemorroids,rectal prolapse,superior cerebellar artery stroke?

P  

Tab  LIVOGEN /PO/OD
Tab ATORVA 20mg/PO/OD
Two egg whites per day
Glycerin dressing daily twice
Vitals monitoring
B12 1000mcg injection IM
Tab FOLVITE 5mg PO/ OD



Comments

  1. general medicineSeptember 27, 2022 at 11:52 PM

    NEUROLOGICAL EXAMINATION

    1. HIGHER MENTAL FUNCTIONS:
    a. Consciousness – intact
    b. Well Oriented to time, place and person
    c. Speech and language – slurring.
    d. Memory – immediate-retention and recall, recent and remote - intact
    a. No Delusions, hallucinations
    b. No Emotional lability
    c. MMSE score
    I. Orientation
    1. date x, day x, month x, season(rainy) yearx (1)
    2. floor x, hospital x. District (1), state , country (1)
    II. Registration
    Name three objects taking one second for each object. Ask him to repeat the same.
    Repeat till he remembers (3)
    III. Attention and Calculation
    Serial 7’s 5 times (0)
    IV. Recall
    Recall the three objects (3)
    V. Language
    1. Name 2 objects (1)
    2. Repeat a sentence (1)
    3. Follow a 3 stage command (3)
    4. Reading “close your eyes”(0) – not able to read
    5. Writing a sentence (0) – not able to write
    6. Copy a design (0)
    2. CRANIAL NERVES
    CRANIAL
    NERVE

    TEST RIGHT LEFT

    I Sense of smell

    i) Sanitizer + +
    II i) Pupillary reflex Normal Cataract
    surgery

    I
    3. MOTOR SYSTEM

    TEST RIGHT LEFT

    I – BULK
    a. Inspection
    b. Palpation
    c. Measurements
    Upper limb – 10cm above and below acromion
    Lower limb 18 cm above and 10 cm below tibial
    tubercle

    Decreased
    Normal
    cms
    cms

    Decreased
    Normal
    cms
    cms

    II – TONE

    a. Upper limbs
    b. Lower limbs

    Hypertonia Hypertonia

    III – POWER
    a. Neck muscles
    b. Upper limbs
    i) Shoulder
    Flexion-Extension
    Abduction / adduction
    ii) Elbow
    Flexion-Extension
    iii) Wrist
    Dorsi flexion-Palmar flexion
    Abduction-Adduction
    iv) small muscles of hand
    v) Hand grip
    c. Lower limbs
    i) Hip
    Flexion-Extension
    Abduction-Adduction
    Lateral Rotation-Medial Rotation
    ii) Knee
    Flexion-Extension
    iii) Ankle
    Dorsi flexion-Plantar flexion
    Inversion-Eversion
    iv) Small muscles of foot
    d. Trunk muscles
    e. Beevor’s sign

    Good
    4/5
    4/5
    4/5
    5/5
    4/5
    4/5
    Good
    Good

    4/5
    4/5
    4/5
    4/5
    4/5

    Weak
    Absent

    Good
    4/5
    4/5
    4/5
    4/5
    4/5
    4/5
    Good
    Good

    4/5
    4/5
    4/5
    4/5
    4/5

    Weak
    Absent

    IV – REFLEXES
    A. SUPERFICIAL REFLEXES
    1. Corneal
    2. Conjunctival
    3. Palatal Reflex
    4. Plantar Reflex
    B. DEEP TENDON REFLEXES
    1. Jaw jerk
    2. Biceps jerk
    3. Triceps jerk
    4. Supinator jerk
    5. Finger flexion reflex
    6. Knee jerk
    7. Ankle jerk
    8. Clonus
    C. PRIMITIVE REFLEXES

    Present
    Present
    Present
    Flexor
    ?Present
    -
    Present
    -
    -
    -
    -
    NT

    Present
    Present
    Present
    Extensor
    Present
    -
    Present
    -
    -
    -
    -
    NT

    D. OTHERS
    Hoffmans sign
    Wartenbergs sign
    Rossalimos sign

    Absent
    Absent
    Absent
    Absent

    Absent
    Absent
    Absent
    Absent

    V – COORDINATION
    TESTED ALONG WITH THE CEREBELLUM

    Impaired
    VI – GAIT Wide based gait
    VII – INVOLUNTARY MOVEMENTS
    A – Athetosis, Asterexis
    B – Ballismus
    C – Chorea
    D – Dystonia
    E – Essential tremors
    F – Fasciculations
    M - Myoclonus

    No

    4. SENSORY SYSTEM
    TEST RIGHT LEFT
    I – SPINOTHALAMIC
    1. Crude touch
    2. Pain
    3. Temperature
    II – POSTERIOR COLUMN
    1. Fine touch
    2. Vibration
    3. Position sense

    1. Tactile localisation
    2. Stereognosis

    Normal
    Normal
    Normal
    Normal
    Normal
    Normal
    Absent
    Normal
    Normal

    Normal
    Normal
    Normal
    Normal
    Normal
    Normal
    Absent
    Normal
    Normal

    5. CEREBELLAR SIGNS
    1. Titubation - absent
    2. Truncal ataxia/gait ataxia/ stance ataxia – present
    3. Nystagmus – absent
    4. Dysarthria - absent
    5. Hypotonia - absent
    6. Rebound phenomenon – absent
    7. Intention tremor - absent
    8. Pendular knee jerk – absent
    9. Tandem Walking – couldn’t elicit due to giddiness
    a. Upper Limbs – Finger Nose test, Finger Finger Nose test – impaired on left
    side.
    b. Lower Limbs – Heel Knee test, - impaired on left side
    c. Dysdiadokokinesia – impaired

    6. AUTONOMIC NERVOUS SYSTEM
    Resting tachycardia- present (?Anxiety)
    Abnormal sweating - no
    7. SIGNS OF MENINGEAL IRRITATION
    Neck stiffness present
    Kernig’s sign - - x
    Brudzinski’s sign - - x
    8. EXAMINATION OF THE SPINE AND CRANIUM
    SPINE – normal
    CRANIUM – normal
    9. PERIPHERAL NERVES
    No Thickened nerves
    No Trophic ulcers
    No Wrist drop
    No Foot drop

    DIAGNOSIS

    Acute Left cerebellar symptoms –
    D/Ds:
    1. ?Acute cerebellar infarct
    2. Multiple system atrophy - cerebellar
    3. Cerebellitis

    ReplyDelete

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