This is a HIPAA de-identified open-online-patient-record, posted on autumn 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive Dr Jyoti.
40 years old woman pain in right side of upper and lower extremities since 1 year along with numbness. Patient complaining pain in abdomen and chest since 1 year. Pain during breathing. Mild swelling on face.
Backache.
Headache since 1yr. Burning on head.head pain during breathing.
Eye__ left eye pain n burning with lacrimation since 1yr.
Neck pain
Anxiety, weakness
Mild facial palsy.
Menstrual/history___ regular
Lmp_ 2/1/2016
Leucorrhoea since 2yrs.
Obs/history__ P4 L4 4normal delivery
LTT done_ 11 yr back.
P/ABD_..Soft LTT scar seen
P/v__ ut_normal
Pulse_ 72/min
BP__ 120/80
Appetite __ decrease
Clinical examination ___
*muscular examination _1.neck_during flexion of neck in slum manuwer rt side tingling & numbness with burning rt side head.
Articular involvement_C2_3_4 area possible remarkable.
Shoulder joint examination _ limit ROM. Exttrnal & internal totation.
Abduction above 90_100 degree pain in acromioclavicular & capsule.
Tingling /numbness in rt arm
Median nerve radial nerve_ more involvement (test by neural stretch test)
Hip joint examination __ hip rt side extensar muscle spasm & mild tingling.
Pain after 70_80degree hip flexion due to muscle spasm.
40 years old woman pain in right side of upper and lower extremities since 1 year along with numbness. Patient complaining pain in abdomen and chest since 1 year. Pain during breathing. Mild swelling on face.
Backache.
Headache since 1yr. Burning on head.head pain during breathing.
Eye__ left eye pain n burning with lacrimation since 1yr.
Neck pain
Anxiety, weakness
Mild facial palsy.
Menstrual/history___ regular
Lmp_ 2/1/2016
Leucorrhoea since 2yrs.
Obs/history__ P4 L4 4normal delivery
LTT done_ 11 yr back.
P/ABD_..Soft LTT scar seen
P/v__ ut_normal
Pulse_ 72/min
BP__ 120/80
Appetite __ decrease
Clinical examination ___
*muscular examination _1.neck_during flexion of neck in slum manuwer rt side tingling & numbness with burning rt side head.
Articular involvement_C2_3_4 area possible remarkable.
Shoulder joint examination _ limit ROM. Exttrnal & internal totation.
Abduction above 90_100 degree pain in acromioclavicular & capsule.
Tingling /numbness in rt arm
Median nerve radial nerve_ more involvement (test by neural stretch test)
Hip joint examination __ hip rt side extensar muscle spasm & mild tingling.
Pain after 70_80degree hip flexion due to muscle spasm.
Notes by the Gynecologist:
