40 year old female with chief complaints of neck pain and dizziness since 10 days
7 Nov , 2023
E LOG GENERAL MEDICINE
Hi, I am G. Akshara , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.
Chief complaints :
A 40 year old female , resident of suryapet , labourer by occupation , came to the OPD with chief complaints of neck pain since 3 days associated with dizziness.
History of present illness :
Patient was apparently asymptomatic 10 days back , and then she developed dizziness which
increased while looking up and also while sleeping , releived by medication.
She also complains of the neck pain which is continuous , dragging type associated with restricted neck movements.
History of past illness :
No diabetes
No hypertension
No TB
No CAD
No epilepsy
No Asthma
Hysterectomy done 20 years ago.
Surgery for renal canaliculi 5 years ago.
Family history :
Non significant.
Allergies :
No allergies
Drug history :
No drug history
Personal history :
Appetite is normal
Mixed diet
Bowel and bladder habits are regular.
Sleep is adequate
No addictions
PHYSICAL EXAMINATION :
A. General Examination
Oral consent is taken.
Examined in a well lit room.
Conscious , coherent and cooperative
Moderatly built and nourished
Pallor is present.
Icterus is absent.
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema is absent.
Vitals :
Temperature: afebrile
Pulse: 84 bpm
Respiration: 17/min
Blood pressure: 130/80 mm of Hg
Spo2: 96%
PHYSICAL EXAMINATION :
A.Cardio vascular system :
Cardiac sounds : S1 and S2
No thrills
No murmurs
B.Respiratory system :
Position of trachea : centre
Shape of the chest : normal
Breath sounds : vesicular
C.Abdomen :
Shape of abdomen : normal
No tenderness
No palpable mass
No organomegaly
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