This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 and come up with a diagnosis and treatment plan.
Following is the view of the case
CHEIF COMPLAINTS:
PRESENTING ILLNESS:
PAST HISTORY
No h/o Diabetes, systemic hypertension, bronchial asthma, pulmonary koch’s, epilepsy, CVA, CAD, and Thyroid disorder
Personal History
Diet: Balanced
Appetite: Normal
Bowl/Bladder:Regular
Sleep: Disturbed
Addictions: Non smoker and non alcoholic
Family history
History of similar complaints in the family
GENERAL EXAMINATION
Patient conscious, coherent, cooperative, comfortably sitting in chair . Moderately built and moderately nourished
Height-170cms Weight-70kgs BMI-(24.2)
No pallor, No icterus, no cyanosis, no clubbing , no lymphadenopathy, no edema,no koilonychia
VITAL DATA:
Temp: 100.2 F
PR: 132/min regular, normal volume, normal character, no radio radial and no radio femoral delay
BP: 110/70mmhg im right upperlimb in sitting position
RR: 28 breaths/min, regular abdomino thoracic type of breathing
Spo2 : 82 on RA and 95 on 8L of O2
CNS :
Right Handed person, studied upto 10th standard.
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
MMSE 26/30
speech : normal
Behavior : normal
Memory : Intact.
Intelligence : Normal
Lobar Functions : Normal.
No hallucinations or delusions.
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
fundal glow present.
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
gaze evoked Nystagmus present.
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION: Right Left
UL LL UL LL
BULK Normal Normal Normal Normal
TONE hypotonia hypotonia hypotonia hypotonia
POWER 5/5 5/5 5/5 5/5
SUPERFICIAL REFLEXES:
CORNEAL present present
CONJUNCTIVAL present present
ABDOMINAL present
PLANTAR withdrawal withdrawal
DEEP TENDON REFLEXES:
BICEPS 2 2 2 2
TRICEPS 2 2 2 2
SUPINATOR 2 2 2 2
KNEE 2 2 2 2
ANKLE 1 1 1 1
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch
pain
temperature
DORSAL COLUMN SENSATION:
Fine touch
Vibration
Proprioception
CORTICAL SENSATION:
Two point discrimination
Tactile localisation.
steregnosis
graphasthesia.
CEREBELLAR EXAMINATION:
Finger nose test
Heel knee test
Dysdiadochokinesia
Dysmetria
hypotonia with pendular knee jerk present.
Intention tremor present.
Rebound phenomenon .
Nystagmus
Titubation
Speech
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT:
wide based with reeling while walking, unsteady with a tendency to fall
unable to perform tandem walking.
Other systems examination
CVS: S1,S2 heard, no murmers
P/A: non tender, no organomegaly
RS: BAE+, NVBS
1)Lt triceps
2)Glabbelar Tap reflex
3)Lt triceps reflex
4)Lt Supinator Reflex
5)Rt Biceps
6)Rt Triceps
7)Rt Supinator
8)Resting Tremors
9)Rt Ankle Jerk
10)Lt Ankle Jerk
11)Lt Plantar Reflex
12)Rt Plantar Reflex
13)Knee Jerk
14)Lt Biceps
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