GM case

July 24, 2023

Case scenario..
Im Sanjana MP, 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This  also reflects my patients centered online learning portfolio.

Case history 
A 65 years old man works as agricultural labour

Cheif complaints:
Abdominal pain,lower back pain and radiating to both the lower limbs,neck pain and stiffness since 1year 
Patient was asymptomatic 1 year ago then he started having neck pain which is insidious in onset , progressive pain, radiating type of pain to both the upper limbs. Restricted neck movement ie difficulty in flexion and extension. Tingling sensation in both the upper limbs.

History of present illness:
Patientvwas apparently asymptomatic 1year back .4 years back patient has history of trauma to right hip so he undergone hemiarthoplasty , after that there was no problem for 3years , 1year back again he developed lower backpain which is of dragging type of pain in both lower limbs ,difficulty in bending and standing after sitting for longer time
Abdominal pain and bloating since 1year

History of past illness:
Loss of appetite,  passing of hard stools since 3months
No history of hypertension, diabetes, tb, epilepsy, CVA,CAD
No any other abdominal symptoms like vomiting , constipation etc
No cough or fever

Personal history:
Appetite- decreased 
Diet- mixed
Bowel- regular
Micturition- normal 
Known allergies- no 
Alcohol- stopped since 3months 

Family history : 
Not significant 

General examination:
Pallor-no 
Icterus-no
Cyanosis-no
Clubbing-no
Lymphadenopathy-no
Abdominal examination:
Shape: obese
Tenderness: no
Palpable mass : no
Hernial orifice : normal
Liver : not palpable 
Spleen: not palapable 
Bowel sounds: present 
Provisional diagnosis:
Neckstiffness : fluorosis
Abdominal pain : gastritis 

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