22-05-2023
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
HOPI-
Patient was apparently asymptomatic 25 years ago then she developed pain from back of neck to lower back throughout the day aggregated by work and relieved by rest. Apparently the pain started post child birth. 16 years ago she went to hospital and was advised exercise but it did not relieve. She developed itchy lesions all over body from the past 2 to 3months
After squatting and when she gets up she has syncopal attack
Past history -
Known case of hypothyroidism and using thyroxine since 2015
Known case of hypertension and using Telma from 2015
In 2016 she got gall stones and cholecystectomy was done
Family history -
Her mother and daughter also have same complaint
Personal history -
Diet - mixed
Appetite - decreased
Sleep - disturbed
Bowl and bladder - regular
Addiction - Tobacco pan everyday for the past 15 years
No allergy
General examination -
patient is conscious coherent and co operative
Well oriented to time, place, person
Moderately built, moderately nourished
Pallor -absent
Icterus- absent
Cyanosis -absent
Clubbing -absent
Lymphadenopathy -absent
Pedal edema -absent
VITALS
TEMP -Afebrile
PULSE RATE -86bpm
PULSE PRESSURE -128/90
RESPIRATORY RATE -16cpm
SYSTEMIC EXAMINATION
CNS EXAMINATION
HIGHER MENTAL FUNCTIONS:
Conscious, oriented to time place and person.
-Speech =Fluency, comprehension, repetition intact
-Memory =Recent, Remote, Immediate: Intact
CRANIAL NERVE EXAMINATION:
1st: Normal
2nd: visual acuity is normal
3rd, 4th, 6th: pupillary reflexes present.
EOM full range of motion present
5th: sensory intact
motor intact
7th: normal
8th: No abnormality noted.
9th,10th: palatal movements present and equal.
11th,12th: normal.
Motor examination:-
Bulk of muscle normal on both sides on inspection
Tone -
Right. Left
Upper limb. Normal. Normal
Lower limb. Normal. Normal
POWER-
Upper limbs +5 in all proximal and distal muscles
Lower limbs -
Rt LT
Iliopsoas- +5 +5
Adductor femoris +5 +5
Gluteus medius +5 +5
Gluteus maximus. +5 +5
Hamstrings +5 +5
Quadriceps +5 +5
Tibialis anterior - +5 +5
Gastrocnemius +5 + 5
Extensor hallucis longus. +5. +5
REFLEXES-
Right. Left
Biceps. ++ ++
Triceps. + + ++
Supinator. + +. ++
Knee. + +. ++
Ankle. + +. ++
Reflex video --
Sensory examination:
1.Spinothalamic: R L
Crude touch + +
Pain ++
2.Posterior column:
Fine touch + +
Vibration Normal
Position sense- normal
3.Cortical
Stereognosis: + +
Graphesthesia +. +
CEREBELLUM:
Finger nose and finger finger test were normal
No dyadiadokokinesia
No pendular knee jerk
Heel knee test: normal
Spine examination: -
No spine tenderness
Straight leg raising test- positive pain at 70° angle
Schober’s test-
Before-15cm
After bending-22cm
CVS:
Elliptical & bilaterally symmetrical chest
-No visible pulsations/engorged veins on the chest
-Apex beat seen in 5th intercostal space medial to mid clavicular line
-S1 S2 heard
-No murmurs
RESPIRATORY SYSTEM:
Upper respiratory tract normal
Lower respiratory tract:
-Trachea is central
-Movements are equal on both sides
-On percussion resonant on all areas
-Bilateral air entry equal
-Normal vesicular breath sounds heard
-No added sounds
-Vocal resonance equal on both sides in all areas.
PER ABDOMEN EXAMINATION --
Scaphoid
-No visible pulsations/engorged veins/sinuses
-Soft, non-tender, no guarding and rigidity, no organomegaly
-Bowel sounds heard
PROVISIONAL DIAGNOSIS: -
This is a case of lower back ache probably due to neural pain
CHIEF COMPLAINTS: -
- Known case of Hypothyroidism since 2008.
- Lower back pain extending from the base of the neck to the hip region since 2008.
History of present illness: -
In the year 2008, the patient has reported to be suffering from lower back pain which was extending from the base of the neck to the hip region. The onset of the pain was sudden, and its presence is continuous. The pain aggravates during the summer season and when the patient bends or sits on the floor to perform some household chores. The pain relieves when the patient is resting, during the winter season, exercising and gentle tugging of hair. The patient also reports experiencing insomnia at the same time. This incidence was seen in the patient's family history, where her mother, father, 2 brothers and one sister also suffered the same condition.
In the same year, the patient reports to be diagnosed of hypothyroidism. There was excessive hair loss and swelling on both lower limbs below the level of the knee were observed. The patient also experiences excessive thirst, drinking 5-6L of water on a daily basis. She started taking Eltroxin 50mcg in the year 2008. In 2015, she took Thyronorm 75 mcg. By the year 2022, she is taking Thyronorm 100 mcg.
History of past illness: -
The patient does not have any history of TB, DM, Epilepsy and asthma.
The patient has undergone gall bladder operation in 2016.
The patient experiences HTN from year 2015.
In 1997, the patient reports to have suffered from cerebral malaria. At the same time there was also swelling of the right arm, which reduced after administration of medications.
Personal history: -
Water intake: - 5-6L daily
Appetite: - normal
Diet: - normal
Bowel and bladder movement: - normal
Addictions: - none
Allergies: - none
Exercise status: - none
Menstrual History: - normal
[9:47 am, 22/09/2025] PPM 1: @PA please update their current weekly blood sugars and blood pressure as demonstrated here👇
Feel free to talk to our patient advocate @RS1 if necessary to understand better how to do it
[9:43 pm, 09/12/2025] PPM 1: Reviewed this patient too in the OPD since yesterday along with her daughter and husband. This is their second visit to our hospital and they had previously visited us thrice in Bhopal too
[8:36 am, 10/12/2025] PPM 1: Her current complaints were the same low backache she's been suffering since the last 3 decades every day 24 hours with intermittent exacerbations. On examination we found trunkal muscle weakness and abdominal obesity, mild hyperglycemia suggestive of metabolic syn and advised diet and exercises for reduction of trunkal fat and improvement of trunkal muscle power.
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