58/M C/O NECK PAIN A/W RESTRICTED MOVEMENTS,B/L INTERMITTENT LOIN PAIN RADIATING TO LT HYPOCHONDRIUM SINCE 10 DAYS
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UNIT 2 ADMISSION
Dr.VAMSHI KRISHNA (INTERN)
Dr.PRADEEP (INTERN)
Dr.JAYANTH (INTERN)
Dr.ISMAIL (INTERN)
Dr.YAMINI (INTERN)
Dr.AMULYA (INTERN)
Dr.PRADEEP (PG 1st YEAR)
Dr. NIKITHA (PG 2nd YEAR)
Dr.SUFIYA (PG 3rd YEAR)
Dr. SATHISH (PG 3rd YEAR)
FACULTY: Dr. VIJAYALAKSHMI
case presentation:
1) 58 year old male came to c/o neck pain a/w restricted movement (since 10 days)
2) pain in B/L loin intermittent radiating upto left hypochondrium (since 10 days)
HOPI
pt was apparently alright 10 days back then he had insidious onset of neck pain which gradually progressed to restricted movement ( not able to move left and right up to down.)
not associated with fever , vomitings, headache, loose stools, blurring of vision
associated with pain in B/L LOIN region intermittent radiating upto left hypochondrium (since 10 days)
pt is K/C/O DM2(SINCE 1 YEAR) ON TAB.GLIMI- M1 ×OD
& HTN (SINCE 1 YEAR) ON TELMA 40 MG × OD
chronic alcoholic (90ml/day) (since 20 years), non smoker
N/K/C/OASTHMA/CAD/CVA
ON GENERAL EXAMINATION:
PT IS C/C/C
TEMP: AFEBRILE
BP:150/90 MM HG
PR:106 BPM
RR: 18CPM
SPO2 :99% @ ROOM AIR
SYSTEMIC EXAMINATION:
CVS: S1,S2 + ,NO ADDED SOUNDS
R/S : BAE +
CNS:HMF INTACT
CN:2 - N
TONE: N
POWER:N 5/5
REFLEXES:
B T S K A P
R+2 +2 - +2 +1 WITHDEAD
L +3 +3 - +3 +1
P/A : SOFT,NON TENDER
DIAGNOSIS:
? CERVICAL SPONDYLITIS
INVESTIGATIONS:
OPTHALMOLOGY
1)INJ.PAN 40 MG /IV /OD
2)INJ. ZOFER 4 MG /IV/SOS
3)INJ. TRAMADOL 1 AMP IN 100 ML NS / IV/TID
4)TAB. TELMA 40 MG /PO/ OD
5)TAB. GLIMI- M1 ×OD
6)TAB. PCM 500 MG×PO/OD
7)TAB. MYORIL 4 MG/PO/BD
8)TAB. SHELCAL CT/PO/OD
DAY 1
1)INJ.PAN 40 MG /IV /OD
2)INJ. ZOFER 4 MG /IV/SOS
3)INJ. TRAMADOL 1 AMP IN 100 ML NS / IV/TID
4)TAB. TELMA 40 MG /PO/ OD
5)TAB. GLIMI- M1 ×OD
6)TAB. PCM 500 MG×PO/OD
7)TAB. MYORIL 4 MG/PO/BD
8)TAB. SHELCAL CT/PO/OD
DAY 2
1)INJ.PAN 40 MG /IV /OD
2)INJ. ZOFER 4 MG /IV/SOS
3)INJ. TRAMADOL 1 AMP IN 100 ML NS / IV/TID
4)TAB. TELMA 40 MG /PO/ OD
5)TAB. GLIMI- M1 ×OD
6)TAB. PCM 500 MG×PO/OD
7)TAB. MYORIL 4 MG/PO/BD
8)TAB. SHELCAL CT/PO
DAY 3
1)TAB.PAN 40 MG /PO/OD
2)TAB. ZOFER 4 MG /PO/SOS
3)TAB.ULTRACET 1/2 ---1/2---1/2---1/2 /PO
4)TAB. TELMA 40 MG /PO/ OD
5)TAB. GLIMI- M1 ×OD
6)TAB. PCM 500 MG×PO/OD
7)TAB. MYORIL 4 MG/PO/BD
8)TAB. SHELCAL CT/PO .
DAY 4
1)TAB.PAN 40 MG /PO/OD
2)TAB. ZOFER 4 MG /PO/SOS
3)TAB.ULTRACET 1/2 ---1/2---1/2---1/2 /PO
4)TAB. TELMA 40 MG /PO/ OD
5)TAB. GLIMI- M1 ×OD
6)TAB. PCM 500 MG×PO/OD
7)TAB. MYORIL 4 MG/PO/BD
8)TAB. SHELCAL CT/PO
9)TAB.GABAPENTIN 100 MG/BD
10) PHYSIOTHERAPY FOR NECK
11)LL ELEVATION
12)CREPE BANDAGE/STOCKINGS
13) GRBS 6 RH RLY
13)
