case3

 Hi, I am Patel Dinesh, 3rd BDS student.

This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

        CASE HISTORY 

A 45 year old female came to GM OPD with

C/o

-Neck Pain since 10 days

-And low grade fever since 10 days. 

HOPI:

Patient was apparently asymptomatic 2 months back then she developed neck pain insidious in onset gradually progressive and aggravated since past 10 days. 

Restriction of movements+.

Neck Pain aggravates on flexion and extension of neck.

No h/o trauma. 

Low grade fever not associated with chills and rigors since 10 days,Intermittent in nature.

No h/o sob,cough,sore throat,Abdominal pain,vomitings,loose stools, Tingling of b/l upper limbs+.

Past History :

K/c/o htn since 4 years and on medication T. losertan 50 mg+Hydrochlorothiazide 12.5 mg po/od 

N/k/c/o DM, thyroid,CVA,epilepsy, Asthma,CAD

Personal History :

Appetite -Normal
Diet -Mixed
Sleep -Adequate 
Bowel and Bladder -Normal and Regular
Addictions -None

Daily Routine:
Patient is a Weaver by occupation. She works at her own house.
She wakes up by 6 am in the morning. She has her breakfast around 8 am. Then she starts her work by 9am. She works till 1pm. Then she has her Lunch by 2pm and sleeps for an hour. She continues her work till 6pm. She then has her dinner by around 8pm and goes to sleep by 10 pm.
The Daily Routine of the patient is disturbed due to severe neck pain since 10 days.

On General examination 

Patient is concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished


No Pallor ,Icterus ,cyanosis ,clubbing , koilonychia ,lymphadenopathy

Bilateral Pedal Edema +


Vitals 


Temperature – Afebrile ( 98.6 F )

Pulse rate – 80 bpm , regular 

Respiratory rate – 16 cpm

BP – 140/90 mm Hg 

SPO2 – 98% on room air  

GRBS – 256 mg/dl


Systemic Examination:


CVS- S1 S2 heard

RS- BLAE +

P/A- Soft,NT BS+

CNS:

HMF - Intact 

Speech – Normal 

Kernigs sign - Negative 

Brudzunski sign - Negative

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15


Clinical Images:













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