30 yrs old female with extension of neck since 2 days

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 This is an 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.

A 30 yr old female resident of adividevulla,came to OPD with cheif complaints of neck stiffness since 2 days.


HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 2days back then she developed neck stiffness towards back and head turned towards to left which was sudden in onset and gradually progressive.her husband was trying to push forwards but it cannot resist forwards so they went to the nearest local hospital.
she complains of headache and giddiness progressively with extensionof neck,  lasting for 1 hr.

H/o giddiness 2 days which was sudden in onset which was aggravated in supine position and doing any work and relieved on rest.so they went to a local hospital.they prescribed some medicines which they were used before the episode.

No h/o fever ,vomitings,seizures,blackouts

No h/o palpitations,breathlessness,

No h/o Syncope,orthopnea,pnd

No h/o difficulty in passing stools and urine

No h/o loss of weight and appeptite
 No h/o any trauma

PAST HISTORY:- H/o of similar complaints in the past 10 yrs ago which were relieved by medication conservatively prescribed bya local practitioner.

H/o sinusitis diagnosed 3yrs ago

 Not a k/c/oDM/HTN/TB/Asthma/CVD/
CAD,epilepsy.

TREATMENT HISTORY:-no significant treatment history 


PERSONAL HISTORY:-

diet: mixed


 Appetite: decreased


sleep: adequate


bowel and bladder:normal


no addictions

FAMILY HISTORY:-

Not relevant  

GENERAL EXAMINATION:-

Patient is drowsy and irritable

Thin built and  moderately nourished 

Pallor - Absent


Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal edema-absent

VITALS:-

Tempurature - 98.6

Pulse- 82 bpm

Blood pressure - 110/70 mmhg

Respiratory rate - 16 cpm

grbs- 124mg/dl

SYSTEMIC EXAMINATION:-

CVS- 

Inspection:-

JVP not seen

Auscultation

S1 S2 heard , no murmurs 

RESPIRATORY SYSTEM

chest is bilaterally symmetrical 

bilateral airway entry present
trachea - Midline 

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

shape- scaphoid

no tenderness

liver not palpable

spleen not palpable



CNS EXAMINATION 

Higher mental functions:

level of consiousness:-consious

speech- normal
 
No hallucinations or delusions

Attitude and position - patient was lying on the bed in supine position 


MOTOR EXAMINATION

Bulk - 
            Rt. Lf 

arm. 25 cm. 25cm

Forearm. 20cm. 20cm

Thigh. 35cm. 30cm

Leg. 28cm. 28cm



Superficial reflexes 

Corneal :present

Conjunctival: present 

Abdominal: present


Tone - Rt. Lf

UL. Normal 23. Normal 23

LL. Normal21 . Normal 21



 Power Rt. Lf

UL. 5/5.  5/5

LL. 5/5.   5/5





Reflexes -

superficial reflexes 

    cornea- present

    conjunctiva - present

   

Deep tendon reflexes-         

                Rt. Lt 

Biceps: 2+ 2+

Triceps 2+. 2+

Supinator. 2+ 2+

Knee. 2+ 2+

 Ankle:2+ 2+

SPINOTHALAMIC SENSATION:

Crude touch

pain

temperature

DORSAL COLUMN SENSATION:

Fine touch

Vibration

Proprioception

CORTICAL SENSATION:

Two point discrimination

Tactile localisation.

steregnosis

graphasthesia


Cerebellar signs :
 Finger heel test : yes
Knee heel test.    :yes
Gait.                      :normal

signs of meningeal irritation-

neck stiffnes- no

kernigs sign-no

Brudzinski -no
                                        
                                  
     
Investigations






Provisional diagnosis : drug induced dystonia .
Dystonia

Treatment:
Inj.calcium gulconate.
Inka.diclofenac





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