40 year old female with chief complaints of neck pain and dizziness since 10 days

 E LOG GENERAL MEDICINE.

Hi, I am G Sai Karthik, 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

• This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
•  * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required

                                   CASE SHEET.                                            

Chief complaints and duration.

A 40 year old female , resident of suryapet , labourer by occupation , came to the OPD with chief complaints of neck pain since 3 days associated with dizziness.

 History of present illness : 

Patient was apparently asymptomatic 10 days back , and then she developed dizziness which 

increased while looking up and also while sleeping , releived by medication.

She also complains of the neck pain which is continuous , dragging type associated with restricted neck movements.

History of past illness :

No diabetes 

No hypertension 

No TB

No CAD

No epilepsy

No Asthma

 

Hysterectomy done 20 years ago.

Surgery for renal canaliculi 5 years ago.

Family history : 

Non significant.

Allergies : 

No allergies

Drug history : 

No drug history

Personal history : 

Appetite is normal

Mixed diet

Bowel and bladder habits are regular.

Sleep is adequate

No addictions

PHYSICAL EXAMINATION : 

A. General Examination

Oral consent is taken.

Examined in a well lit room.

Conscious , coherent and cooperative 

Moderatly built and nourished 

Pallor is present.

Icterus is absent.

No cyanosis

No clubbing of fingers

No lymphadenopathy

Pedal edema is absent.

Vitals : 

Temperature: afebrile

Pulse: 84 bpm

Respiration: 17/min

Blood pressure: 130/80 mm of Hg  

Spo2: 96%

PHYSICAL EXAMINATION : 

A.Cardio vascular system :

Cardiac sounds : S1 and S2

No thrills  

No murmurs

B.Respiratory system : 

Position of trachea : centre 

Shape of the chest : normal

Breath sounds : vesicular 

C.Abdomen : 

Shape of abdomen : normal

No tenderness

No palpable mass

No organomegaly