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...