Rehabilitation Medicine OPD Case Presentation Francisco T, Garcia MI, Gaspar IV, Gatchalian C

General data MMP 35y/o Female Right handed Housewife College graduate Roman Catholic Bicutan Taguig

Chief Complaint Right inguinal pain

History of Present Illness 1 week PTC – After doing her laundry position sitting in a low chair for more than 4 hours with both knee flexed and legs internally rotated – (+) sharp pain at Right inguinal region radiating to middle thigh up to her knee Grade 7-8 Relived by 5-10 minutes stretching Occur after climbing up the stairs No consult or medication taken

History of Present Illness 3 days PTC – (+) numbness of the right middle thigh up to the middle knee – hence consult was done

Past Medical History Non hypertensive, Non diabetic (-) allergies, (-) blood transfusion, (-) trauma, (-)operation, (-) active infectious disease Personal History Denies smoking, Occasional drinker of alcoholic beverages, denies illicit drug use No regular exercise, mixed diet

OB- Gyne History G1P1 (1001) Menarche- 13yrs old Regular : 28-35days cycle Duration of 3 days: 3-4 pads mod soaked Denies dysmenorrhea Denies any use of contraceptive pills Denies any medical problem encountered during and after pregnancy

Family history Father : deceased _ Pneumonia Mother : (+) HPN (-) DM, cancer, OA, RA, Gout, allergy (-) asthma, endocrine problem, musculoskeletal disease

Physical Examination Conscious, coherent, ambulatory, not in respiratory distress BP 120/60 mmHg PR 96 bpm/regular RR 20 cpm/regular T 36.7 o C Wt: 77 kg ; Ht: 165 cm; BMI: 28 Warm moist skin, no active dermatoses, (-) jaundice Pink palpebral conjunctivae, anicteric sclera, pupils 3mm ERTL Fundoscopy: clear disk margin, (-) hemorrhage, (-) exudate, (-) papilledema, cup to disc ratio 0.3, A:V 2:3

Physical Examination No tragal tenderness, midline septum, no nasoaural discharge Moist buccal mucosa, uvula midline, tonsils not enlarged, non-hyperemic posterior pharyngeal wall Supple neck, neck veins not distended, trachea midline, no palpable cervical lymphadenopathies, no thyromegaly

Physical Examination I: Symmetric chest expansion, no use of accessory muscles, (-) intercostal retractions P: Equal tactile and vocal fremiti on both lungs P: Resonant on both lung fields upon percussion A: Clear breath sounds on both lung fields (-) crackles

Physical Examination JVP: 3.5 cm at 30 degrees Carotid pulse: rapid upstroke, gradual downstroke, Adynamic precordium, apex beat at 5 th LICS AAL sustained, localized, no thrills, lifts, heaves, S1>S2 at the apex, S2>S1 on the base, no murmurs

Physical Examination Abdomen: I: Flabby abdomen, no scars, A: Normoactive bowel sounds, (-) bruit P: Tympanitic on all quadrants, Traube’s space not obliterated P: No masses, (-) tenderness, Liver span 8cm, smooth liver edge Musculoskeletal/Extremities: Inspection : No visible lesion/ discoloration bilateral thigh, no cyanosis, no edema, pulses full and equal Knee are equal in height Palpation : There was no swelling, warmth or signs of inflammation bilateral hip, thigh and knees

Physical Examination (+) Straight Leg test Right hip at 45degree angle with (-) Patrick’s(FABER) test bilateral

Neurologic Examination C onscious, coherent, oriented to 3 spheres GCS 15 (E4V5M6) Cranial Nerves: ◦ I – No anosmia, II – pupils 3mm constricting to 2mm ERTL, no ptosis, (+) direct and consensual light reflex, (+) ROR, III, IV, VI – EOMs full and equal, V – Intact sensory (can feel touch in forehead, cheeks, and jaw) and motor, (+) corneal reflex, VII – No facial asymmetry, can raise eyebrows, can frown, smile, and puff out both cheeks, VIII – No hearing deficit and without lateralization, IX, X – Uvula midline on phonation, XI – Can raise shoulder against resistance, XII – Tongue midline on protrusion Cerebellar – can perform FTNT, APST, (-) Romberg test MMT – 5/5 on all extremities No resting, intentional and postural tremors noted Sensory - Intact to pain, temperature, light touch, and vibration DTR’s +2 on all extremities No signs of meningeal irritation No Babinski, no pathological reflexes

Review of Systems GENERAL: (-) fever, (-) weight loss (-) anorexia HEENT: (-)tinnitus, (-) nasoaural discharge, (-) epistaxis, (-) dysphagia HEART: (-) PND, orthopnea, palpitations, dyspnea LUNGS: (-) shortness of breath, (-) cough, (-) sputum, (-) hemoptysis, (-) wheezing, (-) back pain GIT: (-) nausea, (-) vomiting, (-) retching, (-) hematemesis, (-) melena, (-) hematochezia, (-) dysphagia, (-)belching, (-) indigestion, (-) food intolerance, (-) flatulence, (-) abdominal pain, (-) distention, (-) diarrhea, (-) constipation, (-) abdominal enlargement

Review of Systems GUT: (-) urinary frequency, (-) urgency, (-) hesitancy, (-) dysuria, (-) hematuria, (-) nocturia Musculoskeletal: see PE and HPI VASCULAR: (-) phlebitis, (-) claudications, (-) abnormal bleeding, (-) bruising ENDOCRINE: (-) polyphagia, polydypsia, polyuria, (-) heat cold intolerance NEUROLOGICAL: See HPI