PRE - FINAL EXAMINATION CASE

Greetings to one and all who are currently reading my blog. This is Rithika, 9th semester medical student. 
                     
                       This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

Note : This is an on-going case and will be updated as and when I receive any information. 

30 YR OLD FEMALE WITH NECK EXTENSION SINCE 5 DAYS

Chief complaints:

Involuntary neck extension to left side since 5 days

History of presenting illness:

•Patient was apparently asymptomatic 7 days back, then she developed sudden guiddiness, sudden in onset , aggrevated in supine position or while doing any work, relieved on rest. 
•So the couple visited a local hospital the next day, got some medicines prescribed and used them. 
•Then 1 day later, she developed sudden neck stiffness in the back ,  and there was involunyary movement of her head towards left side . Episode was sudden in onset ans gradually progressive . 
•Even though her husband tried to push, the head back in place he couldnt resist .The episode lasted for an hour. 
•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

Daily routine before illness:

Wakes up by 5-5:30am.Prepares breakfast and lunch for family by 8.Has breakfast by 7:30-8am . Gets ready goes to school by 9am(works as an aaya there). Lunch by 12:30-1pm.Comes back home by 4pm.Has some tea in the evening and proceeds with household chores. Prepared and has dinner by 7-7:30pm and sleeps by 9:30pm.

Past history :

•H/o of similar complaint in the past 10 yrs ago  which happened almost a day Or two after her cesarean section for her second child which was relieved by medication conservatively prescribed by 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 and allergies

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

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 - 
                 Right               left

arm.         22cm.            22cm

Forearm. 18cm.             18cm

Thigh.        35cm.           30cm

Leg.            28cm.           28cm

 



Superficial reflexes 

Corneal :present

Conjunctival: present 

Abdominal: present


Tone -          
                Right                    left

UL.         Normal            Normal

LL.         Normal          . Normal 



 Power 
                  Right             left

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+

Cerebellar signs :
 Finger heel test : yes
Knee heel test.    :yes
Gait.                      :normal

signs of meningeal irritation-

kernigs sign-no

Brudzinski -no
                                        
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

PROVISIONAL DIAGNOSIS:

? TETANUS
? FOCAL SEIZURES
? DRUG INDUCED DYSTONIA

INVESTIGATIONS






TREATMENT:



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