A 45 year old female came with C/O pain in left hip since 4 months
Feb 22, 2023
This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.
Name: Manvitha (intern)
A 45 years old female came with C/O left hip pain since 4 months
HOPI
Patient was apparently asymptomatic 3 years back then she had an alleged history of fall in rain and injured her left hip. The pain subsided on its own During past 4 months she is complaining of dragging type of pain radiating to left hip to left ankle not associated with any tingling sensation.
Swelling present 4 months back which subsided on its own
No swelling present now
No tenderness, calf tightness present
Pain aggravates during the walk, no relieving factors
No H/O Fever, joint tenderness, decreased range of movements
Past history
N/K/C/O HTN, DM, epilepsy, asthma ,TB
Past surgery: undergone casesaerean section 11 years back
Personal history
occupation house wife
appetite normal
diet non veg
bowel and bladder movements normal
no addictions
family history insignificant
Menstural history
age of menarche 13 years
regular 5/30 day cycle
General examination
patient is conscious cooperative coherent well oriented to time place person
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
Vitals
temperature : 98 F
PR: 95
RR:16cpm
BP 110/80mmhg
spo2: 98 at room air
Systemic examination
CVS S1S2 heard no cardiac murmurs heard
RS NAD NVBS heard
P/A Soft and non tender scaphoid abdomen
No tenderness
No palpable mass
Hernial orifices normal
No free fluid
No oragnomegaly
CNS :
On day of presentation
Sensory
Spinothalamic tract
Crude touch Right Left
Upper limb Normal Normal
Lower limb Normal Normal
Pain
Upper limb Normal Normal
Lower limb Normal Normal
Temperature
Upper limb Normal Normal
Lower limb Normal Normal
Posterior column
Fine touch
Upper limb Normal Normal
Lower limb Normal Normal
Vibrations
Upper limb
Acromian 7 seconds 6.3 seconds
Olecranon 5 seconds 5 seconds
Lower end of radius 5.8seconds 6 seconds
Lower limb
Tibial tuberosity
Lower limb 6.66 seconds 5.8 seconds
Medical malleous 5 seconds 5 seconds
Cortical
Tactile localisation
Upper limb Normal Normal
Lower limb Normal Normal
Graphesth
Upper limb Normal Normal
Lower limb Normal Normal
Stereognos
Upper limb Normal Normal
CNS
meningeal signs absent
Higher motor functions: conscious, coherent, cooperative, well orinted to time place person
Motor
Lower limb weakness
Hip Right Left
Provisional diagnosis
L5S1 left paracentral disc extrusion with left S1 nerve root compression with left extensior hallucinations weakness D6 hemangioma
Investigations
Treatment
Comments
Post a Comment