A 30 yrs old female with extension of neck since 2 days
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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,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. 22cm. 22cm
Forearm. 18cm. 18cm
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
