75 years male with neck pain and lower back ache since 2 months

4 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 75 year old male , resident of Nalgonda , came to the OPD with chief complaints of neck pain and lower backache since 2 months associated with body pains.

 History of present illness : 

Patient was asymptomatic 2 months back, and then he developed neck pain and lower back pain which was

Incidious in onset

Intermittent type

aggreviated on work

releived by medication.

He also complains of the cough with expectoration which is mucoid and non foul smelling since a week.

History of past illness :

No diabetes 

No hypertension 

No TB

No CAD

No epilepsy

No Asthma

 

Underwent cataract surgery in both eyes 2 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

He was an alcoholic and chronic smoker 3 years back. (1 packet beedi daily )

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 absent.

Icterus is absent.

No cyanosis

No clubbing of fingers

No lymphadenopathy

Pedal edema is absent.

Vitals : 

Temperature: afebrile

Pulse: 78 bpm

Respiration: 16/min

Blood pressure: 110/80 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 : barrel shaped 

Breath sounds : vesicular 

C.Abdomen : 

Shape of abdomen : normal

No tenderness

No palpable mass

No organomegaly