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 box
36 year old female came to OPD with chief complaints of:-
inability to perceive sensations of pain and temperature all over her body since 6 months.
History of presenting illness:-
She was apparently asymptomatic 3 years back ,the she started developing chest pain associated with sensation of cold all over body.
1 month back when she was holding a candle, she couldn't feel how hot it was, while cooking she is unable to feel the hot utensils.
3 days back she had improved sensation after medication (PREGABALIN)
She has history of giddiness (non rotational), complaints of off balance associated with blurring of vision, headache (right temporal region dragging type), aura +, photophobia +
No h/o seizures, disorientation, speech disturbances
No h/o nausea, vomiting, lacrimation or syncopal attacks
Past history:-
Patient was born in 1986, her paediatric history is unremarkable.
Her obstetric history involves 3 surgeries in the years 2008, 2012 and 2015 and
One episode of amenorrhea in 2018.
In 2008 she had her first LSCS, and was diagnosed with eclampsia, there was 1 episode of seizures during labor, otherwise it was a full term delivery.
In 2012 she had yet another LSCS, as she had pre eclampsia, the LSCS was done 2 weeks prior to full term, she had a girl child 2.5 Kgs birth weight.
In 2015 when she was 12 weeks far, she had a history of fall (slipped) and later had bleeding PV, for which her obstetrician advised abortion due to her history of eclampsia.
In 2019 she experienced chest pain associated with sudden onset sob, she was rushed to KIMS NKP, where she was diagnosed with HTN for which she was given TELMA 40 mg and was advised for admission (hypertensive urgency) , but left against medical advice.
In 2021 she started experiencing chest pain associated with cold sensation all over the body since 2 months. She had 2 - 3 episodes last month. Last episode being on - 2/2/22.
She doesn't have any h/o DM, BA, CAD, CVA, Hypothyroid / Hyperthyroid issues,
She has had HTN since 2 years (2019) for which she takes TELMA 40 mg
Personal history:-
She is a married woman with 2 children. She is a home-maker, she has no addictions, her appetite is normal, as are her bowel and bladder movements. Her diet is mixed.
Family history:-
No relevant history.
General examination:-
Patient is c/c/c/, moderately built, moderately nourished.
Pallor- absent
Icterus- absent
Clubbing- absent
Koilonychia- absent
Lymphadenopathy- absent
Edema- absent
Vitals:-
PR - 85BPM
BP - 140/100 mmhg
RR - 20CPM
TEMP - 98.3 F
Systemic examination:-
CVS - S1, S2 +, no murmurs, no visible precordial bulge, no JVP.
RS - BAE+, NVBS heard, no adventitious breath sounds heard.
P/A - scaphoid, soft, non tender, BS +
CNS -
Patient is alert, conscious, HMF intact.
Cranial nerves - intact.
Motor system examination:-
attitude of B/L UL & LL - normal.
bulk of all four limbs - normal.
tone of all four limbs - normal.
power of B/L UL - normal; power is reduced (4-/5) in B/L LL
deep tendon reflexes -
Rt Lt
biceps - 1+ 1+
triceps- 1+ 1+
supinator- - -
knee- - -
ankle- - -
plantar- mute mute
superficial reflexes -
corneal reflex - present
conjunctival reflex - present
Sensory system examination:-
fine touch, crude touch +
pain and temperature - reduced.
vibration and proprioception intact.
cerebellar functions intact, no choreo-athetoid movements
no extra pyramidal symptoms.
gait - normal.
Autonomic system:-
No autonomic symptoms. (irregular sweating/ micturition.....)
Investigations:-
on 8/2/22:
Hb: 12.7gm/dl
TLC: 12,300 CELLS/CUMM
PLATELET: 3.79 LAKHS/CU.MM
SERUM CREATININE: 0.8MG/DL
SODIUM: 140 mEql
POTASSIUM : 4.3 mEql
CHLORIDE: 97 mEql
CUE: NORMAL
ECG:
NORMAL MR VENOGRAM. EEG:- NORMAL
No comments:
Post a Comment