c/o involuntary movements of head since 3 yrs, c/o back pain and right knee pain since 2 years

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.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 diagnosis and treatment plan



The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

Cheif complaints:
Patient came with C/o involuntary movements of head since 3 years
Back pain since 2 years
Right knee pain since 2 years

History of presenting illness:-
A 65 year old female eho was apparently asymptomatic 3 years back and then developed involuntary movements of head, insidious in onset, gradually progressive, continuous , increased with walking and relieved with medication
Low back pain since 2 years, insidious in onset and gradually progressive, non radiating, not associated with tingling and numbness, right knee pain since 2 years, non radiating, not associated with tingling and numbness, relieved with medication 
No h/o headache , fever , vomitings, chest pain, breathlessness, syncope, palpitations, no h/o burning micturition
Not a known case of DM, HTN, epilepsy, asthama, CAD,CVD, thyroid disorders

Personal history:
Diet:mixed
Appetite:normal
Sleep : normal
Bowel and bladder: regular 
Micturition: burning
H/o no addiction

Family history: not significant

General examination: 
Pt is c/c/c moderately nourished and built
No pallor, icterus , cyanosis, clubbing, edema,lymphadenopathy
Vitals :-
Bp : 110/70mmhg
Pr: 82bpm
Rr: 17
Grbs : 129mg/ dl
Cvs : s1 s2 heard
Rs :  bae +, nvbs
P/ a : soft non tender
Cns : hmf +
Cns tone RT LT
             Ul. N. N
             Ll. N. N     
 
Power.        RT   LT

            UL. 5/5  5/5
            LL. 4/5  5/5
Reflex:
            B +2       +2 
            T +2.      +2
             S +1      +1
             K +2       +2
             A   -           -
             P   F        F
Rombergs : negative
Dysdidokinesia :- negative

Reports :-

Provisional diagnosis: ? Atypical                  Parkinsonism 
Treatment:
Tab.pacitane 2mg po od
Tab.pcm 500 mg po bd
Tab.supradyn po od

Comments

Post a Comment

Popular posts from this blog

72Y Male with SOB and fever since 7 days

Image
Patient came with C/o fever since 2 days  C/o breathlessness since yesterday HOPI :- patient was apparently asymptomatic 2 days back then he developed fever which is insidious in onset ,gradually progressive, continuous low grade with chills and rigors relieved with medication. Breathlessness since yesterday insidious in onset gradually progressive present even at rest , NYHA GRADE IV ,not relieved with rest , associated with cough with expectoration which is white in colour. No h/o pedal edema , abdominal distension. H/o decreased urine output and burning micturition. Past history:- Not a k/c/o DM,HTN,BRONCHIAL ASTHMA , THYROID AND SEIZURE DISORDERS K/c/o TB 8 years back used medication. General examination:- pt is C/C/C. Pallor + , no cyanosis, icterus, clubbing, lymphadenopathy, edema. Temp - 100.8F  Bp - 100/60mmhg Pr- 104 bpm Spo2 - 75 at RA at admission  Addictions :- alcoholic and tobacco chewer since 40 years. Systemic examination:- CVS - S1S2 heared, No murmurs. RS - NVBS CNS
Read more

medicine posting journey in my internship 2018

Image
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-centered online learning portfolio and your valuable inputs on the comment" Posted in Medicine department from 1/12/23 - 31/1/24 1/12/23 - 15/12/23 : Unit 16/12/23 - 31/12/23 : Peripherals 1/1/24 - 15/1/24 :Unit 16/1/24 - 31/1/24 : Psychiatry  1) Self reflective writing on their medical student career . I am an intern sneha yerukala 2018 in the medicine department. I have been working here for the past 2 months and I am here to share with you what I learned from this amazing experience. - First of all, I would like to thank my HOD and all the staff, Pgs , a
Read more

complaint shivering of hands and legs since 2 months

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.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 diagnosis and treatment plan The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  Che
Read more