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.
HOPI-
Patient was apparently as
ymptomatic 25 years ago then she developed pain from back of neck to lower back throughout the day aggregated by work and relieved by rest. Apparently the pain started post child birth.16 years ago she went to hospital and was advised exercise but it did not relieve.
She developed itchy lesions all over body from the past 2 to 3months
After squatting and when she gets up she has syncopal attack
Past history -
Known case of hypothyroidism and using thyroxine since 2015
Known case of hypertension and using telme from 2015
In 2016 she got gall stones and cholecystectomy was done
Family history -
Her mother and daughter also have same complaint
Personal history -
Diet - mixed
Appetite - decreased
Sleep - disturbed
Bowl and bladder - regular
Addiction - tobacco pan everyday since 15 year
No allergy
General examination -
patient is coinscious coherent and co operative
Well oriented to time ,place ,person
Moderately built ,moderately nourished
Pallor -absent
Icterus- absent
Cyanosis -absent
clubbing -absent
Lymphadenopathy -absent
Pedal edema -absent
VITALS
TEMP -afebrile
PULSE RATE -86bpm
PULSE PRESSURE -128/90
RESPIRATORY RATE -16cpm
SYSTEMIC EXAMINATION
CNS EXAMINATION
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
-Speech =Fluency,comprehension,repetition intact
-Memory =Recent,Remote,Immediate : Intact
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
Motor examination :-
Bulk of muscle normal on both sides on inspection
Tone -
Right. Left
Upper limb. Normal. Normal
Lower limb. Normal. Normal
POWER-
upper limbs +5 in all proximal and distal muscles
Lower limbs -
Rt LT
Iliopsoas- +5 +5
Adductor femoris +5 +5
Gluteus medius +5 +5
Gluteus maximus. +5 +5
Hamstrings +5 +5
Quadriceps +5 +5
Tibialis anterior - +5 +5
Gastrocnemius +5 + 5
Extensor hallucis longus. +5. +5
REFLEXES-
Right. Left
Biceps. ++ ++
Triceps. + + ++
Supinator. + +. ++
Knee. + +. ++
Ankle. + +. ++
Sensory examination:
1.Spinothalamic: R L
Crude touch + +
Pain ++
2.Posterior column:
Fine touch + +
Vibration Normal
Position sense- normal
3.Cortical
Stereognosis: + +
Graphesthesia +. +
CEREBELLUM:
Finger nose and finger finger test were normal
No dyadiadokokinesia
No pendular knee jerk
Heel knee test : normal
Spine examination: -
No spine tenderness
Straight leg raising test- positive pain at 70° angle
Schober’s test-
Before-15cm
After bending-22cm
CVS:
Elliptical & bilaterally symmetrical chest
-No visible pulsations/engorged veins on the chest
-Apex beat seen in 5th intercostal space medial to mid clavicular line
-S1 S2 heard
-No murmurs
RESPIRATORY SYSTEM:
Upper respiratory tract normal
Lower respiratory tract :
-Trachea is central
-Movements are equal on both sides
-On percussion resonant on all areas
-Bilateral air entry equal
-Normal vesicular breath sounds heard
-No added sounds
-Vocal resonance equal on both sides in all areas.
PER ABDOMEN EXAMINATION --
Scaphoid
-No visible pulsations/engorged veins/sinuses
-Soft,non tender, no guarding and rigidity, no organomegaly
-Bowel sounds heard
PROVISIONAL DIAGNOSIS:-
This is a case of lower back ache probably due to neural pain
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