KIM ADRIAN C.

LOMPOT
BES MARIE LORENZO
RANNAH KRIZIA LU

MEDICINE 3

Patients 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

was admitted. Diagnostic procedure was done and was found out to have a low level of potassium. The
patient treated to normalize the potassium level.
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, hence sought admission to our hospital institution.

Past Medical History

Age

Date

27

2012

Description/Diagnosis/Managem
ent
Rashes, documented fever up to
41 C, numbness and muscle
weakness/Dermatomyosistis/Pre
dnisone 15mg 2x a day, 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. Patient now worked as a Pastor on their church. Patient is a nonsmoker, and non- alcoholic. Patient eats 3-4 times a day and is a vegetarian. She is allergic to soap, lotion,
petroleum jelly, shrimps and chicken.
Gynecologic History
Patients first menstruation was at the age of 16. Her menstrual period is irregular with an average
flow usually lasts for 5 days. She usually consumed 4 pads a day during her first 2 days of menstruation.
Her last menstrual period was on August 25, 2015.
Obstetric history
Patient is a nulligravid.

Review of Systems
General: With weakness and easy fatigability. No loss of appetite, but loss of weight noted.
Skin: History of rashes was noted. No sores, bruising or pigmentations; no changes in hair and nails.
Head: No history of head injury.
Eyes: Wears corrective glasses. No significant visual dysfunction.
Ears: No deafness, tinnitus, or discharges.
Nose and sinuses: History of epistaxis was noted. No history of sinusitis or obstructions.
Mouth and Throat: No bleeding gums or sores. no history of sore throat and tonsillitis.
Neck: No stiffness or limited range of motions.
Breast: No masses, tenderness, or nipple discharges.
Respiratory: History of dyspnea and shortness of breath, and asthma was noted. No history of hemoptysis.
Cardiovascular: No hypertension, chest pain and palpitations. No ankle swelling or edema.
Gastrointestinal: No history abdominal pain and bloating. No reported changes in bowel habits or
significant stool changes. No hemorrhoids.
Genitourinary: No dysuria, flank pain, or urinary incontinence and frequency. No abnormal discharges or
hematuria.
Musculoskeletal: With muscle weakness, numbness and pain with significant muscle wasting. Muscle
fatigue/weakness when climbing stairs, walking, rising from a seated position, combing hair and brushing
teeth was noted.
Neurological System: Weakness and numbness on upper and lower extremities was noted. No history of
seizure or epilepsy noted.
Endocrine system: No significant polyuria or polydipsia. No heat and cold intolerance or any abnormal
sweating.
PhysicalExamination
General: The patient is awake, alert, and responsive. She is wellgroomed, appears calm, and is
cooperative.Thepatientisafebrileandnotinrespiratorydistress.
VitalSigns:
BP110/70
HR84bpm
PR82bpm
Temp36.5oC
RR21cpm
Skin:Thepatienthasbrownskin,dry,smooth,andwarmtotouch,withgoodskinturgor.Noopen
wounds,rashesorotherlesionsnoted.Noclubbingorcyanosis.
HEENT:
Head: Skullisnormocephalic.Withoutlumps,lesions,depressions,ordeformities.black,andequalin
distribution. Scalp has noscales, lumps, or other lesions. Face is symmetrical, without tics, spasms,
involuntarymovements,edema,ormasses.

Eyes: Pupilsareequallyround,andreactivetolightandaccommodation.Patienthaspinkconjunctiva.
Extraocularmusclefunctionsequalandintact,withoutptosisornystagmus.Nopapilledema.
Ears: Theauricleshavenodeformities,lumpsorabnormalsecretions.
Nose: Nasalmucosaispink,septumisinthemidline.Nosinustenderness.Nostrilspatent,without
nasalflaringordischarges.Nonasalpolyps,ulcers,orbleedingnoted.
Neck: Necknormalinsize.Nomassesorsignificantscarsseen.Noenlargementsorpalpablelymph
nodes.Tracheainthemidline,withoutdeviation.Noenlargementofthyroid.
Throat:Lipsaremoist.Therewerenoulcersnorcracking.Tongueispink,inthemidline.Uvulaisinthe
midline,withoutanydeviation.Tonsilsarenotinflamed.
Respiratory:
Chestissymmetrical,withoutdeformitiesorretractions.Breathingisspontaneousandwithouteffort.No
tendernessormassesnoted.Tactilefremitusisequalonalllungfields.Resonancenoted,equalonall
lungfields.Clearbreathsoundsnoted.
Cardiovascular:
Anteriorchestissymmetrical.PMIisatleft5thintercostalspace.Cardiacrhythmisregular.Nomurmurs
orextrasounds.Noheavesorthrills.
Abdomen:
Abdomenissoft,flat,withoutvisibleorganenlargement.Nostriae,scars,dilatedveins,rashes,orlesions.
Umbilicusisinthemidline,withoutinflammationorherniation.Tympaniticabdomenuponpercussion.
Liver is dull upon percussion. No shifting dullness. No tenderness over entire abdomen. . With
normoactivebowelsounds.
Peripheralvascular:Normalpulseintensityonalloftheextremities.
GenitourinaryNotassessed.
Musculoskeletal:Lesionsandmassesarenotnoted.Therearenodeformities.A2inchlongitudinalscar
isnotedontheleftinnerthighwherebiopsyofmuscletissuewasobtained3yearsago.Bothupper
extremitiesarenormalintermsofmotorandsensoryfunction.Itisalsocoordinatedandsymmetrical.
Shedevelopedbilaterallowerextremityparalysis.Bothlowerextremitiesareweakandspastic,however
itismorepronouncedontheleftleg.Sensoryfunctionintermsofpain,vibrationandpressureisalsoless
ontheleftleg.Patienthasdifficultyinsittingdownwithdangledlegsforalongtime.Sheisalsounable
tomoveherlegsinvoluntarilyandcannotwalkwithoutassistance.
Neurologic:Patientorientedtotime,placeandperson.Displaysappropriateaffect,coherentlyanswers
questions.Patellarreflexintact.Cranialnervesintactwithnormalfunction.

Salient Features:
Female Gender
History of Dermatomyositis
Numbness and weakness on lower extremities
Epistaxis
Dyspnea
Uncontrollable shaking
Physical examination:
Bilateral lower extremity paralysis.
Both lower extremities are weak and spastic, however it is more pronounced on the left leg.
Sensory function in terms of pain, vibration and pressure is also less on the left leg.

Differential Diagnosis
Disease
1. Multiple Sclerosis

Rule In
leg numbness
leg weakness
poor balance
muscle spasticity
(especially in the
legs)
feeling of fatigue

2. Guillain Barre
Syndrome

3. Multiple Sclerosis

4. 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

Presence of
abnormal reflex
Twitching muscles
Foot drop
Depressed
reflexes
atrophy