55yr female with bilateral flank pain

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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 plan.

Case-

A 55 year old patient came to the opd with the cheif complaint of pain in the flank since 2 months

History of presenting illness-

The patient was apparently asymptomatic 2 months back. Later she developed pain in the flanks on both sides that was sudden in onset and presents with a dragging type of pain. 

There is history of cough, shortness of breath, nausea, severe weight loss and loss of appetite. 

There is not history of fever, burning micturition. 

History of past illness-

History of coronary artery disease, hypertension and epilepsy.

She has stopped taking her medication since 7 days.  

Last episode of epilepsy was 3 years back. 

No history of diabetes, tuberculosis, asthma. 

Personal history-

Diet- mixed                                       Appetite- reduced

Bowel and bladder- regular              Sleep- reduced 

Allergies- none.                                 Addictions- none

Family history- not significant 

General Examination-

Patient is conscious, coherent and cooperative.

Severely undernourished and thinly built.

Gait normal 

Temperature- afebrile

Pulse- 103 beats per minute 

Blood pressure- 130/90 mmHg

Respiratory rate- 24 cycles per minute 

Pallor- present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent 

Oedema- absent

Systemic examination-

CVS- S1, S2 sounds heard, no murmurs heard

Respiratory- NVBS heard with shallow breaths    

GIT- abdomen not distended, umbilicus central.

 

  On palpation a firm mass felt around umbilicus    with clear borders.

              Abdominal aortic pulse felt with light palpation and hand moved with the aortic pulse.

   

On auscultation bowel sounds heard, with a heavy aortic pulse likened to a thud sound. 

CNS- Feeling of pins and needles in the right side of the body

          Unable to lift right hand to full extent.

          Tremors present on exertion

           Power of limbs normal

           No additional neurological deficit

Investigations-

 CBP

CUE

LFT

RFT

Fasting blood sugar

2D Echo 

ECG

X-ray-

    C-spine

      LS-spine

    X-ray chest

Diagnosis- Aortic sclerosis with abdominal aortic pulse.