I am Saranya ,currently an intern posted in the department of General Medicine
Greetings to all my readers;
This is an elog documenting the patients that I witness during my Rotatory Internship Postings to enforce a greater patient centered learning
DEIDENTIFICATION :
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CONSENT :
An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
ACKNOWLEDGMENT
I convey my regards to Dr. Lohith and Dr.Narsimha Readdy ( Resident , Department of General Medicine ) for guiding me regarding the case .
INTRODUCTION :
My patient is a 55 year old lady, a homemaker , resident of a rural district of South India
CHIEF COMPLAINTS :
A 55 year old lady came with the complaints of difficulty in walking since the past 6 months.
c/o Left lower limb pain and Left lower limb weakness since 4 to 5 months both upper and lower limbs
Timeline of her disease process
( BioPsychosocial data compiled )
TRYING TO DOCUMENT THE LIFE OF OUR PATIENT IN THE FORM OF A STORY
( P.S. : HENCE TRIED TO CHOOSE A FONT WITH A SIMILAR FEEL )
Her day would begin with notes of prayers by her grandparents, there would be lush greenery all around as soon as she stepped out of home , thanks to the Indian village being her home.
Soon she would get her self ready and head out, ready to walk quite some distance to reach her wee little school where she enjoyed with her friends ,played and learnt too.
Coming back home , even though young she would lend a helping hand to her mother in the many household chores ,since they were a family of many , and she was expecting younger siblings too.
Our patient was born in a common Indian household in the 1960s .She was the second eldest among the four siblings.
She was raised in a rural background ,in a family where the parents were engaged in daily wage work ,earning square meals for their children ,but at the end of the day ,they were a happy family.
She still remembers how beautifully all her cousins ,her neighbors would come together and celebrate the festivities ,even though they would not be pompous ones but they would merry moments .
As they say , good times often pass in a blink , so went her childhood days ,as adolescence arrived ,soon the parents began the preparations of getting the daughters married , and it was her turn
.
But all stories do not have a happy ending ,there were some issues which cropped up between the two families , a kind of tension was built , and the very next day of her marriage her husband and her in-laws refused to accept her , hence she never went to her in -laws home.
This somehow affected her a lot as a person, she curled herself into a shell, reduced meeting up with people , avoided attending family functions,
With time ,all her siblings got married ,shifted off to different areas , and her parents passed away.
She began living all by herself, managing all the household chores , the economic side by engaging in daily labor work , and also carrying her emotional burdens . All by herself.
This was a quick snapstory about her background .
Timeline continued :
2 years back : History of slip and fall , trauma to left wrist , which was managed conservatively ( according to the patient ,documented records not available )
Post treatment she became fine ,and remained alright until 6 months back when she had developed difficulty in walking, due to which is unable to do her routine work .
She also could not lift heavy weights, hence had to stop going to her labor work.
she also had complaints of
weakness in left lower and upper limbs,
weakness is insidious onset gradually progressive in nature
Pain and tenderness present in the deltoid area (left side) and pain aggravated on over head abduction and tenderness present.
Patient complaints of " shooting type " of pain in the left lower limb from hip to toe, which is aggravating on walking,
Due to pain Pateint while walking she feels as if she’s going to fall down
c/o pain in the left deltoid region since 5 to 6 months with c/o pain during movement .
No h/o head trauma and LOC
No ent bleed
Not aK/c/o HTN, DM CVA CAD,TB asthma etc
Quick glance at her gait.
Click on this link
https://youtu.be/Equma9NCeCw
General and Systemic Examination:
CLINICAL PICTURES :
CVS Examination : S1 , S2 heard , no murmurs
Respiratory Sys. Ex : Normal bilateral air entry ,normal vescicular breath sounds heard , no added sounds.
P/A : Soft and non tender.
CNS Examination
Reflexes Rt. Lt
Biceps. +++ +++
Triceps. + +
Supinator +++ +++
Knee + +
Ankle ++ ++
Plantar Flexion Flexion
Tone Right Left
Upper Limb Hypertonia Hypertonia
Lower Limb Hypertonia Hypertonia
Power Right Left
Upper Limb 5/5 5/5
Lower Limb. 5/5 4-/5
Bradykinesia present ,
Patient stumbles at turnings
B/L Asymmetric Cogwheel rigidity
Festinating gait
Decreased arm swing and mask like facies
INVESTIGATIONS :
Orthopedics and Neurophysician opinion taken.
Advice by Orthopaedician : No immediate intervention needed from their end.
Advice by Neurophysician : Clinically, Patient diagnosed with Idiopathic Parkinson's Disease
PROVISIONAL DIAGNOSIS
IDIOPATHIC PARKINSONS DISEASE
TREATMENT GIVEN
INJ.OPTINEURON IN 100 ML N.S IV /OD
TAB.PREGABALIN-M 75MG PO/HS
TAB. SYNDOPA PLUS 125MG 1/2 PO/BD
Advice at Discharge
TAB.SYNDOPA PLUS 125MG 1/2 PO/BD 8AM-8PM X 14 DAYS
TAB.MVT PO/OD X14 DAYS
No comments:
Post a Comment