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KIM ADRIAN C.

LOMPOT
BES MARIE LORENZO
RANNAH KRIZIA LU

MEDICINE 3

Patient’s Name:

Cruz, Redelyn

Age:

30

Sex:
Address:
Civil Status:
Religion:
Race:
Occupation:

Female
Tacurong City, Sultan Kudarat
Single
Protestant
Filipino
Pastor

Education:

College Graduate

Date and Time of Admission: August 25, 2015 @ 1:30 pm
Date and Time of Assessment: August 26, 2015 @ 4:30PM
Hospital:

San Pedro Hospital

Ward:

St. Dominic

Informant:

Patient

Reliability:

100 percent

Chief Complaint: Numbness

History of Present Illness:
3 weeks prior to admission, patient experienced numbness and muscle weakness on her lower
extremities that occur especially at night. She got difficulty of sleeping and just massages her extremities
and changes her position in bed just to relieve the numbness. No medical consultation was done.
Interim, the above symptom still persisted and no medical consultation was done.
2 days prior Admission, minutes upon waking up, patient experienced epistaxis which lasted for
10 mins. After she rested for about an hour, she experienced difficulty of breathing. Minutes later the
patient then experienced numbness starting from the upper down to the lower portion of the body
associated with uncontrollable shaking. The patient was being rushed to a local hospital in Midsayap and

Patient now worked as a Pastor on their church. Her menstrual period is irregular with an average flow usually lasts for 5 days. Patient eats 3-4 times a day and is a vegetarian. Obstetric history Patient is a nulligravid. She usually consumed 4 pads a day during her first 2 days of menstruation. lotion.alcoholic. shrimps and chicken. Past Medical History Age Date 27 2012 Description/Diagnosis/Managem ent Rashes. Physical Therapy sessions Hospital Clinic Dubai Immunizations Patient did not received a complete set of immunization Family History Maternal Hypertension Allergy Asthma Paternal Diabetes Siblings Personal /Social history Patient worked as a sales agent in Dubai 3 years ago but came back to the country when she was diagnosed with dermatomyosistis. and non. Her last menstrual period was on August 25. 2015. . petroleum jelly. hence sought admission to our hospital institution. Diagnostic procedure was done and was found out to have a low level of potassium. numbness and muscle weakness/Dermatomyosistis/Pre dnisone 15mg 2x a day. The patient treated to normalize the potassium level. Patient is a nonsmoker. On the day of admission she was advised by the doctor in charged in Midsayap to seek further consultation on a tertiary hospital in Davao city especially to her neurologist for further assessment and diagnosis.was admitted. documented fever up to 41 C. She is allergic to soap. Gynecologic History Patient’s first menstruation was at the age of 16.

Musculoskeletal: With muscle weakness. rising from a seated position. rashes or other lesions noted. or deformities. No ankle swelling or edema. Ears: No deafness.   She   is   well­groomed.  spasms. numbness and pain with significant muscle wasting.   appears   calm. or urinary incontinence and frequency. or discharges. no changes in hair and nails. black.   or   other  lesions. Genitourinary: No dysuria. or nipple discharges.  Vital Signs: BP – 110/70 HR – 84 bpm PR – 82 bpm Temp – 36. Muscle fatigue/weakness when climbing stairs. walking.   without  tics.   and   is cooperative. No significant visual dysfunction. combing hair and brushing teeth was noted. smooth. tenderness. dry. Cardiovascular: No hypertension. but loss of weight noted.   lumps. Neurological System: Weakness and numbness on upper and lower extremities was noted. Head: No history of head injury. Gastrointestinal: No history abdominal pain and bloating. edema. No open wounds. Respiratory: History of dyspnea and shortness of breath. chest pain and palpitations. No history of hemoptysis. No sores.  . Without lumps. bruising or pigmentations. and asthma was noted. and equal in distribution. No reported changes in bowel habits or significant stool changes. No history of seizure or epilepsy noted.Review of Systems General: With weakness and easy fatigability. lesions. no history of sore throat and tonsillitis. involuntary movements. Endocrine system: No significant polyuria or polydipsia. Mouth and Throat: No bleeding gums or sores.   and   responsive. flank pain. and warm to touch.   Scalp  has   no scales. The patient is afebrile and not in respiratory distress. depressions. Breast: No masses.   alert. Nose and sinuses: History of epistaxis was noted. with good skin turgor. Neck: No stiffness or limited range of motions.  HEENT:  Head:  Skull is normocephalic.   Face  is  symmetrical. No abnormal discharges or hematuria. tinnitus. No history of sinusitis or obstructions. No loss of appetite. No heat and cold intolerance or any abnormal sweating. No hemorrhoids. Eyes: Wears corrective glasses. Physical Examination General:   The   patient   is   awake. Skin: History of rashes was noted. No clubbing or cyanosis.5 oC RR – 21 cpm Skin: The patient has brown skin. or masses.

  Neurologic: Patient oriented to time. Peripheral vascular: Normal pulse intensity on all of the extremities. Cardiac rhythm is regular.   . without ptosis or nystagmus. without nasal flaring or discharges. flat. No murmurs or extra sounds. No enlargement of thyroid. Displays appropriate affect. equal on all lung fields. coherently answers questions. and reactive to light and accommodation. Tonsils are not inflamed. rashes. in the midline. It is also coordinated and symmetrical. septum is in the midline. She is also unable to move her legs involuntarily and cannot walk without assistance.Eyes:  Pupils are equally round. Sensory function in terms of pain. Both lower extremities are weak and spastic.   No   tenderness   over   entire   abdomen. however it is more pronounced on the left leg.   No   shifting   dullness. Nostrils patent. Uvula is in the midline.   With normoactive bowel sounds. A 2­inch longitudinal scar is noted on the left inner thigh where biopsy of muscle tissue was obtained 3 years ago. Patient has pink conjunctiva. lumps or abnormal secretions. Umbilicus is in the midline. ulcers. Tongue is pink. scars. Extra ocular muscle functions equal and intact. No heaves or thrills. place and person. She developed bilateral lower extremity paralysis. without deviation. Abdomen:  Abdomen is soft. dilated veins.  Nose:  Nasal mucosa is pink.  Throat: Lips are moist. or lesions. No striae. Trachea in the midline. Patellar reflex intact. There are no deformities. without inflammation or herniation. No papilledema. vibration and pressure is also less on the left leg. without visible organ enlargement. Tympanitic abdomen upon percussion. No enlargements or palpable lymph nodes.  . Breathing is spontaneous and without effort. without deformities or retractions. or bleeding noted. Clear breath sounds noted. No nasal polyps. Both upper extremities are normal in terms of motor and sensory function. No sinus tenderness. Ears:  The auricles have no deformities. Patient has difficulty in sitting down with dangled legs for a long time.  Neck:  Neck normal in size. Resonance noted. PMI is at left 5th intercostal space. There were no ulcers nor cracking.  Cardiovascular:  Anterior chest is symmetrical. Liver   is   dull   upon   percussion.  Musculoskeletal: Lesions and masses are not noted. No masses or significant scars seen. No tenderness or masses noted.  Respiratory:  Chest is symmetrical. Tactile fremitus is equal on all lung fields.  Genitourinary Not assessed. Cranial nerves intact with normal function. without any deviation.

however it is more pronounced on the left leg. Sensory function in terms of pain. Both lower extremities are weak and spastic. Differential Diagnosis Disease 1. Multiple Sclerosis - Rule In leg numbness leg weakness poor balance muscle spasticity (especially in the legs) feeling of fatigue - 2. vibration and pressure is also less on the left leg. Guillain Barre Syndrome - 3. Amyotropic lateral sclerosis - weakness in the lower extremities leg paralysis weakness is worst at night feeling of fatigue - numbness and weakness in leg loss of balance uncontrollable shaking breathing problems Difficulty walking Weakness in legs Breathing difficulties - - - Rule Out no impaired vision no pins and needles sensation no bladder problems no cognitive dysfunction no ptosis paralysis is ascending no dyspnea no bladder control difficulty no dysphagia no blurring of vision Slurring of speech Trouble swallowing Difficulty holding your head up . Multiple Sclerosis - 4.Salient Features: Female Gender History of Dermatomyositis Numbness and weakness on lower extremities Epistaxis Dyspnea Uncontrollable shaking Physical examination: Bilateral lower extremity paralysis.

- Presence of abnormal reflex Twitching muscles Foot drop Depressed reflexes atrophy .