GM case-2
CASE scenario....
Hi,I am R.Tharshik kumar,3rd BDS student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning
Case History
Chief complaints
A 65year old male patient resident of nalgonda farmer by occupation came to OPD with chief complaints of
Abdominal pain since 1 year
Lower back pain radiating to lower limbs
Neck pain and stiffness since 1year
History of present illness
Patient was apparently asymptomatic 4 year. 4years ago patient has H/O trauma (he had fall while taking his cattle to the field) of right hip and hemianthroplasty was done. then he started having neck pain since 1yr and radiation to bilateral upper limb which is insidious in onset gradually progressed to current.
Difficulty in flexion and extension of neck and tingling sensation of bilateral upper limb
Patient gradually developed low backache pain and which is dragging type of pain to lower limbs since 1year
Patient also complaints difficulty in bending, difficulty in getting up from sitting position ,joint stiffness abdomen pain and bloating and belching.
He also complaints loss of Appetite and passage of hard stools since 3month and
Negative history - no Malena , constipation, vomiting ,sob,chest pain ,cough ,fever.
History of past illness
N/k/c/o HTN, DM,CVA,CAD ,TB, epilepsy Treatment History:
Hemianthroplasty of right hip 4,years ago
Personal History:
Married
Agriculture labour
Loss of appetite
Mixed diet
Normal micturition
No known allergies
Addictions - occastional (stopped since 5 month)
Family History
Not significant
General examination:
Patient is concious, coherent and cooperative
No pallor,
No icterus,
No clubbing of fingers,
No lymphadenopathy,
No cyanosis,
No edema.
Temperature:afebrile
Pulse rate:68/min
Respiratory rate:16/min
BP:130/70mmhg
Spo2:98%
Systemic Examination
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
no dyspnea
No wheezing
central trachea
vesicular breath sounds
Abdomen
Obese shaped abdomen
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
Neck stiffness present
INVESTIGATION:
ECG
