33F with neck pain


Hi, this is Shreshta Reddy Adla, a medical student currently studying in KIMS Narketpally. This page is a compilation of cases taken up during my medical school years, with an intent to correlate theoretical concepts of medicine to practical aspects of it. These E-logs have been created after taking consent from the patient and the patient's advocate. So welcome, and I encourage you to immerse yourselves into these interesting cases.

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.


Aa 33 year old female patient teacher by occupation came to the General Medicine OPD with 

CHIEF COMPLAINTS 

Neck pain since 4 months

- Leg pain since 4 months


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 4 months ago then she developed bilateral neck pain which was insidious in onset, not progressive, intermittent in nature. The pain is of dragging type radiating to shoulders and upper back . There are no aggravating factor and pain is relieved on rest.

It is associated with headache.


Patient also complaints of bilateral leg pain since 4 months which is insidious in onset, not progressive, intermittent in nature. The pain is of dragging type radiating to thighs and lower back. The pain is 

aggrevated on long standing and relieved on rest .


NEGATIVE HISTORY 

Not associated with fever, vomitings, diarrhoea .


PAST HISTORY -

Not a k/c/o DM, HTN, TB, asthma, epilepsy

No history of previous surgeries

No history of blood transfusion


FAMILY HISTORY -

Not relevant


PERSONAL HISTORY -

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder movements regular

No allergies

No addictions 


GENERAL EXAMINATION -

Patient is c/c/c and id examined in a well ventilated and lit room with consent 

No Pallor, icterus, cyanosis, pedal edema, generalised lymphadenopathy,

Clubbing of fingers .


VITALS

Bp- 110/90 mmHg.

Pulse rate - 80 bpm

RR- 16 cpm

Temp- afebrile






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