A 65 year old male with abdominal pain neck pain and neck stiffness

July 24,2023

Hi,I am Nidhi 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.

                        CASE SHEET

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

HOPI:

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

PAST HISTORY:

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,icterus , clubbing of fingers, lymphadenopathy, cyanosis and edema



VITALS
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
USG

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