Medicine log

E-LOG MEDICINE



-108 Koushik 


This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 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, come up with a diagnosis and treatment plan.



A 20 year old female hailing from nagarjunsagar nursing student by occupation came to OPD with chief complaints of unable to walk since one and half year and difficulty in  passing stool and urine one and half year back.


History of presenting illness:

Patient was apparently asymptomatic 1 year back then she had fever which lasted for about 10 days by the end of 10th day patient said that she fell from the bed in the morning when she was trying to get up  and couldn't walk.

Her mother and father lifted her up and put her on the bed,after some time she experienced tingling sensation in both the lower limbs.

She was unable to pass urine and stools from that day.

She gave no complains of difficulty in combing her hair, no difficulty in mixing of food. 
She had difficulty in getting up or turning in the bed.

Past history :
Patient complained about having jaundice during childhood.

Patient was diagnosed with hypothyroidism
4 yrs back for which she used medication (Thyronom).

Not a known case of  hypertension,diabetes,cad,asthma,epilepsy,tuberculosis.

Personal history:

Sleep:adequate 

Diet:mixed 

Appetite:normal 

Bowel and bladder:irregular 

Addictions:none 

Menstrual history:

Age of menarche :13 years 

Regular cycles 

2-3 pads per day.

Family history:

Mother and father diagnosed with hypertension since 1 year 

No similar complaints in the family.

Treatment history:
Tablet Thyronom 50mg 

General examination:
Patient was conscious,coherent,cooperative well oriented to time,place and person

Built:thin 

Nourishment: moderately nourished 

Vitals:
Temperature:Afebrile 

Respiratory rate: 12-14 cycles/minute 

Bp:110/70 mmHg

Pulse:80 beats/min


No pallor,icterus,cyanosis,clubbing,lymphadenopathy,pedal edema.

Systemic examination:

CNS EXAMINATION:

Sensory: Normal

Level of consciousness:conscious 

Speech :Normal 

Signs of meningeal irritation: no 

Cranial nerves:Normal 

Motor:

Bulk: Right upper arm:22cms
          Right forearm :20 cms
  
          Left upper arm:21 cms
          Left arm :19.5 cms 
    
          Right thigh:25 cms 
          Left thigh:25 cms
    
          Right leg:18 cms
          Left leg:18 cms

Reflexes:

Biceps:absent

Triceps:absent

Supinator:absent

Knee:absent

Ankle:absent 

Plantor:babinski sign positive(flexion of great toe present)

CVS:

S1 S2 heard

No murmers

Respiratory:

B/L air entry is present 

Trachea centrally present 

No dyspnea,wheezing

Per abdomen:


Shape of abdomen:scaphoid

No tenderness

No organomegaly 























Provisional diagnosis:

Transverse myelitis?


























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