A65 yr old male with cc of lower backache associated with neck pain

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.




A 65 year old male ,  came to casualty with the c/c of lower backache  since 3 days which is radiating to both lower limbs and associated with neck pain since 3 days.

History of present illness
Patient is suffering from lower back ache which is radiating and associated with neck pain .
Difficulty in movement of head 
No history of fever,parasthesia and early morning joint stiffness

History of past Illness 
K/c/o Hypertension since a week
N/k/c/o  DM, CVA,CAD,TB,Asthma

Patient  has an RTA 1 year back & underwent s/p Implant in the left femur.

Personal history
Marital status: married
Occupation: Vendor 20 yrs back
Appetite : Normal
Bowels: Regular
Micturition : Normal
Allergies:No
Diet: Vegetarian
Habits: Alcoholic (Regular)

Family history

No significant family history. 


General Examination


Patient was conscious, coherent and cooperative 

No icterus,pallor,lymphadenopathy,clubbing of fingers & toes
Vitals:
Temp - afebrile 
Pr :78bpm
Rr 22cycles/min
BP 120/80 mmhg 
Spo2 98% at room air 







Systemic Examination 


CVS - s1 s2 + ,No murmurs 
RS - BAE + 
Abdomen- scaphoid,nontendor,not palpable,
Liver not palpable
Spleen : not palpable
Bowel sounds :Yes

CNS - 
Conscious
Speech- normal
Neck stiffness- No
Kerning's sign- No
Cranial nerves-normal
Motorsystem-normal
Sensory system-normal
Glasgow scale- normal

Investigations




 

Provisional diagnosis- 
Cervical spondylosis


Treatment
Tab ultracet 
Tab zincovit 
Tab shelcal
Cap myoril
Tab amlong

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