General medicine case discussion

April 24th Case scenario.......

Hi, I am M.Yamini , 5th sem medical April 17th Case scenario.......

Hi, I am M.Yamini , 5th sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:The 28 year old female occupation farmer came ,from West Bengal to general medicine opd 

Chief complaint s:
Pain & weakness in right upper limb & lower limb

History of presenting illness:
Patient was asymptomatic 8 year s ago , while watering in garden she got musle sprain in back 
Onset: insidious
Pain: dragging type of pain 
Radiation: Radiating towards the left lower back then right upper limb & lower limb
Aggregating factors: while doing normal moment s, increase s in night time
Relieving factors: pain is relieved by medication & massage
3 years ago patient consulted to orthopaedic put on some medication,then she relieved her pain,she discontinued her medication
Then Doctor asked  for investigation like X ray & blood
Then he adviced to refer neurologist
They didn't consult any neurologist came to Kims narketpally
No h/ o fever,headache, vomiting,

Past  history:
No h/o DM, hypertension, epilepsy,CVD, asthma, tuberculosis

Family history: not significant

Personal history:
Diet: mixed
Appetite: normal
Bowel & bladder movement s: Regalar
Married
2 boys (11 yr & 8 year old ) 
Allergy of egg one year ago ,she developed rashes on fire arm .
Addiction:pan & tobacco chewing since 4 years ,3 times per day.
General examination:
 Patient is consious, coherent, cooperative,well oriented with the & place
Pallor: absent
Icterus: absent
No lymphadenopathy
No cyanosis
No clubbing
Vitals:
Heart Rate:74 BPM
Respiratory time: 18 time

CNS Examination
Motor Examination:
Tone  : Right                       left
Biceps hypotonia             Normal
Triceps Normal                Normal
Lower limb  Right Normal    Normal
Power
Upper limb: 
Right.                  Left
Biceps:+2          +5
Triceps:+5        +5
Supinator:+5      +5
Power
Upper limb.                           Right   Left
Elbow extension flexion   4/5      5/5
Wrist flexion extension    5/5      5/5
Lower limb
Knee flexion extension     5/5   5/5
Ankle dorsiflexion             5/5   5/5
Bulk
Upper limb
Arm               8.5 inch   9 inches
Forearm      8.5 inch   8.5 inches
Lower limb
Leg       12 inches   12 inches
Reflexes
Upper limb     Right    Left
Biceps         Not seen   normal
Triceps     any reflexes
Supinator
Lower Reflexes
Right       Left
+3          +2
Ankle
Right     Left 
+1       +2
Plantar reflex 
Right    Left 
+2        +2
Gait abnormality...




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