A 55 year old female with headache, neck pain.

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 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

 

 A 55 year old female, farmer by occupation, resident of chityal, came to casualty with chief complaints of headache with neck pain since 15 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 15 days ago, then she developed headache which was insidious in onset, non progressive, is present most time of the day, non pulsatile, diffuse, dull aching type, radiating to neck. There was restriction of movement in the neck, aggravated on extension of neck, no relieving factors. It is associated with giddiness, tingling sensation of both upper limbs, extending from palm to above. There is history of 20 days ago, diagnosed as typhoid by local doctor, relieved on medications. No history of blurring of vision, convulsions, vomiting, photophobia, phonophobia, joint stiffness, twitching. No history of loss of consciousness, altered sensorium, delusions, hallucinations, slurring of speech. No history of drooping eyelids, deviation of eyes. No history of deviation of mouth, drooling of saliva. No bowel abnormalities. No vomiting, trauma.


PAST HISTORY:

Patient is not a known case of hypertension, diabetes mellitus, TB, epilpesy, asthma, CAD.


PERSONAL HISTORY:

Diet is mixed. Appetite is normal. Sleep is adequate. Bowel and bladder movements are regular. History of hysterectomy 11 years ago. No addictions. No known allergies.


FAMILY HISTORY:

Not significant.


GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and moderately nourished. No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema. 

BP: 100/70mmHg      PR: 78bpm    temp:afebrile    RR: 14 cpm


SYSTEMIC EXAMINATION: (Central nervous system)

(A) Higher mental functions:

conscious

orientation time, place and person

Speech and language- normal

memory- immediate, recent and remote- good

no delusions, hallucinations.

(B) Cranial nerve

                                       R                                                         L

          I                           +                                                          +

          II                          N                                                         N

         III, IV, VI          Eom +                                                  +

                    indirect pupillary  +                                           +

                    direct pupillary  +                                               +

                               ptosis     -                                                    -

          V    sensory       N                                                          N

                 motor          N                                                         N

                 reflex           +                                                          +

         VII       

            motor: NL        present                                              present

                       buccinator    good                                           good

           sensory: taste         N                                                     N

          reflex:             present                                                   present

        secretomotor           N                                                     N

       VIII

          Rinnes                 +                                                         +

          Weber                          not lateralised

          nystagmus           abnormal                                         abnormal

        IX, X

         uvula                                      centrally placed

        gag reflex                               present

        palatal reflex                         present

       XI 

        trapezius                          good                                   good

       sternocleidomastoid       good                                   good

      XII

        tone                                  N                                          N

        wasting                            -                                            -

       tongue protrusion                         ----normal----

 (C)  Motor system

       Bulk                                  N                                           N

        Tone     UL                     N                                            N

                       LL                     N                                           N

       Power    UL shoulder     4/5                                       4/5

                      UL elbow            4/5                                      4/5

                      UL wrist             4/5                                       4/5

                      LL  hip               5/5                                        5/5

                       LL knee            5/5                                         5/5

                      LL ankle            5/5                                        5/5

     Reflexes  corneal                  Pr                                        Pr 

                      conjunctival          Pr                                        Pr

                      palatal                    Pr                                         Pr

                       Abd.                        Pr                                        Pr

                      plantar                         --- hyper extension---

                      biceps                     Pr                                         Pr

                      triceps                    Pr                                         Pr

                     supinator                Pr                                         Pr

                     knee                         Pr                                         Pr

                    ankle                         Pr                                          Pr

     Gait- normal

involuntary movements: none

(D) Sensory system

                  crude touch                 N                                         N

                   pain                              N                                        N

                   temp                            N                                          N

                   rombergs                 absent                                  absent

                 2 point dis                    N                                           N

                 tactile localisation      N                                           N

                  graphaesthesia           N                                           N

(E) Cerebellar signs

 NO titubation. No dysarthria. No nystagmus. No hypotonia. finger nose test- normal   finger finger nose test- normal   dysdiadakinesia- normal

(F)  No signs of meningeal irritation


PROVISIONAL DIAGNOSIS:

Neck pain under evaluation...


INVESTIGATIONS:



          

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