general medicine blog 3
59yrs/M with c/o incecred sugar levels
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
Chief compaints
c/o pain in neck and knee pain since 3 months
HOPI:
Patient was apparently asymptomatic 8 months back over which he developed c/Io of chestpain, sob grade 3 and then consulted a private hospital where angioplasty was done . He is put on medication since then using regurally.
C/o pain in the neck since 2-3 months which is non radiating
Past history
He has DM 2 since 1.5 yrs
And HTN since 3 months
PCTA -8 months (angioplasty/angiogram was done)
No history of Tb, epilepsy, CVA, THYROID DISDORDERS.
Personal history
Diet - Mixed
Appatite - Normal
Sleep - Normal
Bowel and Bladder -Regular.
Allergy - None
Addictions -Alcohol addiction but stopped after angioplasty
Somking stopped 4 yrs back
No durg addiction
Micturation-normal
Family history
No significant family history
Mother has HTN
GENERAL EXAMINATION:
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
Pallor -present
Icterus- absent
Clubbing-absent
Cyanosis-absent
Lymphadenopathy-absent
Edema - absent
VITALS:
Temperature - 96.8 F
Blood pressure - 140/80mmHg
Pulse rate - 82/ minute
Respiratory rate - 18/minute
SYSTEMIC EXAMINATION:
CVS:
S1 and S2 heard.
No addded thrills or murmurs heard
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
Bilateral air entry present.
ABDOMEN:
INSPECTION:
shape of abdomen - scaphoid
umbilicus -central
no sinuses
No scars
PALPATION:
Tenderness+ liver and spleen was palpable
PERCUSSION:
No shifting dullness
AUSCULTATION:
Bowel sounds +
CNS:
Conscious and coherent.
Normal sensory and motor responses
INVESTIGATION
CERVICAL SPONDYLITIS
