30 years old female with c/o neck stiffness
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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, clerk by occupation came to OPD with cheif complaints of neck stiffness since 2 days.
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 5days back then she developed headache insiduous in onset progressive in nature (more in the frontal region ) no aggravating and reliving factors .The next day she developed giddiness for which she went to local hospital and was treated (treatment unknown).she became normal and the next day she went to her work and in the morning she developed neck pain which is severe and for that she went to the same local hospital and was taking treatment and in the middle of the treatment she developed neck stiffness towards back side and head turned towards to left which was sudden onset and gradual progressive.she complains of headache and giddiness on extending neck to left side progressively with extension, lasting for 1 hr.
H/o giddiness which was sudden in onset aggravated in supine position and relived on rest.
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
bilateral airway entry present
PERSONAL HISTORY:-
diet: mixed
Appetite: decreased
sleep: adequate
bowel and bladder:normal
no addictions
DAILY ROUTINE:
5: 30 : wakes up.
6:00- 7:30: house work
7:30-8:00: bathing and breakfast
8-9 am: gets ready to school
9-9.15am :- prayer
9.15- 1 pm: school attendence
1-2 pm:lunch
2-4:30pm: school work
5-6pm:takes bath and washes clothes
6-7.30 pm: house work
7.30-8 pm - watch tv
8-9 pm- dinner.
9 pm : goes to bed.
MENSTRUAL HISTORY:-
Age menarche -13year
28/5 ,regular .
FAMILY HISTORY:-Not relevant
GENERAL EXAMINATION:-
Patient is conscious and coherent well oriented to time place and person
Thin built and moderately nourished
Pallor - Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal edema-absent
VITALS:-
Tempurature - Afebrile
Pulse- 82 bpm
Blood pressure - 110/70 mmhg
Respiratory rate - 16 cpm
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
Noscars
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
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
Cerebellar signs :
Finger nose test : yes
Knee heel test. :yes
Gait:normal
signs of meningeal irritation-
neck stiffnes- no
kernigs sign-no
Brudzinski -no
