A 55 year old male came to general medicine OPD with the chief complaints of Headache, Neck and back pain

16/12/2022 

Hi I am K.Sai Rithindar Reddy of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of his/her condition.

A 55 year old married male laborer came from narketpally to general medicine OPD with the chief complaints of pain in head, neck and back since 1 week

HISTORY OF PRESENT ILLNESS: 

He was apparently asymptomatic 1 week ago
From 1 week he developed dragging type of pain in head, neck and back which was gradually increasing and resistant to NSAIDS given by a local RMP whom he consulted on the day of onset. The pain in head was starting in the temporal region and extending upto the occipital region and waxing and waning and was associated with increased pain in the sleeping side when lying down side ways. It is associated with tingling sensation when exposed to light.Not associated with nausea and vomiting. The neck pain was bilateral and extending upto xiphoid process anteriorly, acetabulum laterally, C-7 to T-1 spine of vertebrae posteriorly.
4 days ago the pain became unbearable associated with fatiguability, weakness of muscles, SOB and abdominal discomfort which made him to come to KIMS

PAST HISTORY: 

15 years ago he met with a RTA by car dash when he was in a rickshaw and undergone surgeries for his fractures in patella, tibia, radius and ulna.
He was diagnosed with hypertension 1 year ago but only used medication for 3 days before coming to OPD.
He was diagnosed with diabetes 1 week ago by a local nurse but didn't use any medication. 
No history of epilepsy, TB, asthma.

FAMILY HISTORY: 

Non consanguinously married 35 years ago and had 4 daughters and a son who are married and healthy
No history of HTN, DM, TB, epilepsy and asthma.

PERSONAL HISTORY: 

Mixed diet
Normal appetite
Lack of sleep due to pain
Normal micturition
Normal bowel movements 
Occasional alcohol intake of 90-180ml 3 times per a month
Tobacco intake of 20 pack years of sutta
No allergies

DRUG HISTORY :
Tab. Atenolol for 3 days before coming to OPD

GENERAL EXAMINATION: 

Conscious coherent and cooperative 
Moderately built 
Moderately nourished 
No pallor
No icterus
No pedal edema
Lymphadenopathy of submandibular lymph nodes
No clubbing of fingers
No cyanosis

VITALS:

Heart rate:60bpm
Respiratory rate: 19 per min
Blood pressure: 170/100 mmHg

INVESTIGATIONS : 

USG ABDOMEN REPORT:

LABORATORY INVESTIGATIONS: 

ECG: 
PROVISIONAL DIAGNOSIS: 
Hypertensive Urgency 


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