Case history prefinals

 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.

CHIEF COMPLAINT-

A 17 years old female came to OPD with a chief complaint of weakness in the upper and lower limb since 4days.

Tingling and numbness in the palms and soles since 4 days.

HISTORY OF PRESENT ILLNESS -

The patient was asymptomatic 4 days back  then she has sudden onset of pain in the calf muscles since 4 days followed by unable to stand from sitting position.

Able to roll on bed.

No history of fever,loose stools, vomitings.

HISTORY OF PAST ILLNESS-

Not a known case of DM, Epilepsy, HTN

Asthma, TB.

PERSONAL HISTORY-

Diet- mixed 

Appatite- normal.

Bowel movement- regular.

Mituration- decreased since 3 days.

Addictions- none.

FAMILY HISTORY-

No family history.

DRUG HISTORY- 

No drug history.

 PHYSICAL EXAMINATION -

GENERAL-

Patient was concious, coherent and cooperative.

Pallor- No.

Icterus- No.

Cynosis- No.

Clubbing- No.

Lymphadenopathy- No.

Edema of feet- No.

VITALS -

Temperature- afebrile.

Pluse rate- 98BPM

BP- 140/90 mm/hg.

Respiratory rate-20/ beats.

SYSTEMIC EXAMINATION-

CVS- 

1. S1 and S2 heard.

2. Thrills- No.

3. Cardiac murmurs- no 

RESPIRATORY SYSTEM 

1. Dyspnoea- No.

2. Wheeze - No

3. Position of Trachea- Central.

4. Breath Sounds - Vesicular.

ABDOMEN-


1. Shape of abdomen - Obese

2.Tenderness- Not

3. Palpable mass- no.

4. Hernial Orifices - Normal

5. Free Fluid- No

6. Bruits- No

7. Liver - Not palpable

8. Spleen- Not palpable 

9. Bowel sounds - No.

CNS -

1. Level of consciousness- concious.

2. Speech- normal.

3. Neck stiffness- No.

4. Cranial nerve- normal.

5. Coordination- Present.






INVESTIGATION-










TREATMENT-
























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