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.
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
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