Imama Muhmeen : 67 year old female pt with cervical and lumbar spondylitis

This is an a 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

COMPLAINTS AND DURATION:

A 67 y/o female presented with c/o tingling, numbness and weakness in both hands since 20 days.

C/o sob since 1 month

H/o fever 1 week back

Neck pain( radiating type), lower back aches (radially to lower limbs) and pain in b/l upper and lower limb since 6 months

Blood in stools since 1 year?

Burning micturition since 3 months (on and off)

History of Presenting Illness:

Pt was apparently asymptomatic 6 years back when she developed tremors in both hands. Insidious in onset and gradually progressive in severity. Not affecting day to day activities.

-2 years back pt had continous white discharge for 1 month for which she was evaluated and diagnosed with carcinoma cervix and received chemotherapy and radiotherapy for 1 month.

- since 1 year back pt has developed passage of blood in stools (dark to bright red in color) frank blood present

• upper gastric endoscopy and colonoscopy were done and showed radiation proctitis.

PAST HISTORY:

N/h/o loose stools or vomitings

H/o occasional fever (low grade) associated with chills relieves on medication, no diurnal variations

N/h/o cough,

Pt is a k/c/o b/l osteoarthritis knee for which she takes medications I.e nsaids intermittently

N/k/c/o - htn, dm, asthma, Thyroid disorders, epilepsy,

PERSONAL HISTORY:

Normal appetite,

Vegetarian diet with regular bowel and bladder habits

No known allergies

Addictions - toddy once a month

Non smoker, no other drug use

FAMILY HISTORY:

TREATMENT HISTORY:

MENSTRUAL HISTORY:

OBSTETRIC HISTORY :

GENERAL EXAMINATION:

O/e PT IS C/C/C

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION:

PR-98 BPM

BP- 110/70MM HG

RR- 18 CPM

SPO2- 99% AT RA

GRBS - 103mg/dl

SYSTEMIC EXAMINATION:

CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL. BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

PER ABDOMEN:

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT