MASINDEMULIROUNIVERSITYOFSCIENCEANDTECHNOLOGY

SCHOOLOFPUBLICHEALTHBIOMEDICALSCIENCESANDTECHNOLOGY

DEPARTMENTOFHEALTHPROFESSIONSEDUCATION

COURSE;CLINICALPLACEMENT

COURSECODE;BSP318

ROTATION;MEDICALWARD3

NAME;

REGNO;SPR/B/01-03241/2021
TO;MRROBERTOUMA

CLINICALINSTRUCTOR;...................................................DATE;....................SIGN;.............
........
PATIENTBIODATA
NAME:G.W
AGE:15YEARS
GENDER:MALE
RESIDENCE:NAVAKHOLO
OCCUPATION:STUDENT
NEXTOFKIN:AUNT
NEXTOFKINNAME:J.W
RELIGION:CHRISTIAN
NATIONALITY:KENYAN

CLINICALDATA.
IPNO:250648
MEDICALDIAGNOSIS:MALARIAANDSEVEREANAEMIA
DATEOFADMISSION:2NDFEBRUARY2024
DATEOFCLERKING:7THFEBRUARY2024
CHIEFCOMPLAIN.
Neckstiffness3/7
Generalizedbodyweakness1/52
Neckpain3/7
HISTORYOFPRESENTINGILLNESS.
Twoweeksago,thepatientcomplainedoffrequentvomitingandheadache.HewastakentoNavakholoho
spitalwherehewasdiagnosedwithanaemiaandmalaria.HewasthenadmittedinNavakholoHospitalfor
aperiodofoneweekbeforebeingtransferredtoKakamegaGeneralHospital.Threedaysago,hestartedco
mplainingofneckpainandhaddifficultyindoingneckmotions.
PASTMEDICALHISTORY.
ThisishissecondadmissionashisfirstadmissionwasinNavakholoHospital.
HehasahistoryofbloodtransfusioninNavakholoHospital.
Nohistoryofanysurgeries.
Nohistoryofanychronicillness.
FAMILYHISTORY.
Hisfatherdiedduetoaroadtrafficaccident.
Hismotherisstillalivealthoughheliveswithhisgrandmother.
Hehasthreeothersiblings.
Nohistoryofanychronicillnessinthefamily.
SOCIALHISTORY.
Heisagrade8studentatMusavalejuniorschool.
Nohistoryofalcoholintakeorcigarettesmoking.
Hisauntusescashforhismedicaltreatment.
ENVIRONMENTALHISTORY.
Theyliveinasemi-permanenthouse.
Helivesinaflatterrainarea.
Heliveswithhisgrandmother.
Summary;thepatientisa15-year-
oldboypresentingwithneckstiffnessandhasbeendiagnosedwithsevereanaemiaandmalaria.

OBJECTIVEASSESSMENT.
Generalobservation.
Heappearsgenerallyweak.
Heexperiencespainwhenperformingneckmotions.
Hehasacannulaonhisrightforearm.
VITALS.
Bloodpressure-132/85mmHg
Pulserate-80bpm
Breathingrate-25bpm
Temperature–37.5oC
CARDIOVASCULARSYSTEM.
Oninspection,heappearspale,thereisnocyanosisandnojaundice.
Onpalpation,thecapillaryrefillislessthan2secondsandtheradialpulseisregular.
Nomurmursareheard,ands1ands2soundsareheardonauscultation
Insummary;thepatientispale.
RESPIRATORYSYSTEM.
Oninspection;normalchestriseandfallpatterns.
Onpalpation;thetracheaisnotdeviated.
Onpercussion;aresonantsoundisheard.
Onauscultation;breathsoundsareheard.
Insummary;therespiratorysystemisnormal
MUSCULOSKELETALSYSTEM.
Painandtendernessonpalpationoftheneckregion.
Thepatientcomplainsofpainwhendoingrangeofmotionmovementsoftheneck.
Musclepower:
Flexorsandextensorsoftheupperlimb;5/5
Flexorsandextensorsofthelowerlimb;5/5
Summary:thepatienthasdifficultyinmovementsoftheneck.
SPECIALTESTS.
Brudzinskitest;withthepatientlyingsupine,thepatient`sneckispassivelyflexed.Thetestwasnegativea
stherewasnoinvoluntaryflexionofthehipandknees.
Thenegativetestshowedthatthepatienthadnosignsofmeningitis.
PROBLEMLIST.
Neckpainonascaleof7/10.
Neckstiffness.
Difficultyinperformingactiverangeofmotionsoftheneck.
Physiotherapydiagnosis;neckrigidityduetoprolongedbedrest.
TREATMENTPLAN.
Short-termgoals.
Toreducetheneckpainfrom7/10to5/10inthefirsttwosessionsofthetreatment.
Toincreasetheneckrangeofmotionmovementsbytheendofthefirstweek.
Toreduceneckstiffnessthroughmassageandexerciseswithinthefirstweekoftreatment.
Long-termgoals.
Toachievealong-termreductioninpainfrom7/10to1/10after1monthoftreatment.
Toattainfullrangeofmotionoftheneckafter4weeksoftreatment.
INTERVENTIONS.
Neckrangeofmotionexercises;
Neckflexionandextensionbydoing5repetitionsin2sets.
Necklateralflexionbydoing5repetitionsin2sets.
Neckrotationandchintucksbydoing5repetitionsin2sets.
Shouldershrugexercises;bydoing5repetitionsin3sets.
Softtissuemassage;toenhancerelaxationandimproveflexibilityontheneck.
Breathingexercises;pursedlipbreathingexercisebydoing10repetitionsin3sets.
Education;onproperneckpostureandreducingprolongedforwardheadposture
EVALUATION.
Onevaluation,thepatientcomplainsofmildpainontheneck.
FOLLOW-UPPLAN.
Encouragedthepatienttocontinuedoingtheactiverangeofmotionexercises.