A 55 y/o female with bilateral lower limb pains and left side headache since 2 months

 A 55 y/o female with complaint of bilateral lower limb pain since 2 months and left side unilateral  headache since 2 months and falling of teeth since 4 years

M.sandhya 

roll no 94


This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box
55year old female who is a housewife    and came to opd with

CHIEF COMPLAINTS;

complaint of bilateral lower limb pain since 2 months and left side unilateral  headache since 2 months and falling of teeth since 4 years

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 months back then she developed having lower limb knee pains(more on right side knee)not associated with any swelling, decreased range of movements
there is difficulty in getting up from sitting position and morning stiffness present
no,h/O tingling sensation,numbness and lossing of sensation. 

unilateral  left side headache since 2 months picking type of pain associated with photophobia phonophobia blurring of vision present (for far vision) no h/o vomiting watering of eyes neck pain fever burning micturition 
not using any spectacles

HISTORY OF PAST ILLNESS:

k/c/o DM II since 4 years on regular medication 

N/k/c/o HTN, ASTHMA, EPILEPSY, CVA AND CAD

FAMILY HISTORY:-
insignificant 
PERSONAL HISTORY:-

DIET-mixed
APPETITE-normal
BOWEL and BLADDER-regular
SLEEP-Adequate.
ADDICTIONS- No

GENERAL EXAMINATION:-

Patient is conscious , coherent,cooperative.
Well oriented to time place & person 
Moderate built and moderately nourished.
Pallor absent
No cyanosis, clubbing, icterus, LN

Vitals : 
Bp -100/70 mmhg
PR -92 bpm ;
RR : 16cpm
Spo2 : 96 on RA
GRBS:141 mg/dl
CENTRAL NERVOUS SYSTEM;
patient is conscious 
speech is normal
no signs of meningeal irritation
Sensory examination: Normal
reflexes;      
                   RIGHT            LEFT

BICEPS       +2                     +2

TRICEPS       +2                     +2

SUPINATOR    +1                   +1

KNEE                  +2                    +2

ANKLE                +2                     +2
Rhomberg's negative
Cerebellum:
Nystagmus-absent
Tremors- absent
Finger nose test- normal
Dysdiadokinesia- absent

CARDIOVASCULAR SYSTEM:-
S1 S2 heard 
No murmurs.
RESPIRATORY SYSTEM:-
Dyspnea-absent
No wheeze
Breath sounds - vesicular
No Adventitious sounds 
ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - Present 

INVESTIGATIONS;

ECG:


2D-ECHO 

USG ABDOMEN:

Right knee x-ray:







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