60YR OLD MALE PATIENT WITH HEAD ACHE AND NECK ACHE

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Name : Supriya .K ( Intern ) 

Roll Number : 63 

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

60YR OLD MALE PATIENT, RESIDENT OF NARKETPALLY , DAILY WAGE WORKER BY OCCUPATION CAME TO THE OPD WITH 

Chief complaints of ; 

Neck pain since 6 days 

Headache since 6 days 

B/L shoulder pain since 6 days 

Blurring of vision since 1 year 

Patient was apparently asymptomatic 6days ago,then ,he developed headache over B/L temporal region and occipital region ,which is of half n hour duration ,episodic ,no aggravating factors but relieved on medication ,not associated with nausea, ,vomiting ,photophobia ,phonophobia .

Then he developed Neck pain ,which is of dragging type ,diffuse and associated with B/L Shoulder pain 

H/O blurring of vision since 1 year 

H/O RTA 15 years ago ,which lead to the Fracture of Right sided Tibia , Right sided knee joint and Right sided Radial bone fracture (UNDERWENT SURGERY )and 




Head ache started since then (as his head got hit to the ground )which was on and off and dull aching ,diffuse and pain increased in intensity since 6 days and associated with neck pain and bilateral shoulder pain but there was NO H/O Fracture to the Skull not associated with abrasion ,contusion or lacerations over the head . On Radiological examination ,which was done before ( CT scan & MRI - No abnormality detected ). 

No Deviation of Mouth 

No Weakness of limbs 

No H/O chest pain 

No H/O palpitations

No H/O SOB 

K/C/O Hypertension ,which was diagnosed 7 days ago ( used atenolol as medication ) 

N/K/C/O  DM II , TB , Epilepsy,Asthma ,CVA ,CAD 

PERSONAL HISTORY : 

Appetite : Normal 

Diet :  Mixed 

Sleep : adequate 

Bowel and bladder movements: regular 

Addictions: Occasional alcoholic , Smoking since 45years ( Chutta - 4/ day ) 

Allergies : No allergies 

GENERAL EXAMINATION: 

Patient  is conscious ,coherent , cooperative, Moderately Built and Moderately Nourished .

Temp: Afebrile 

BP : 190 /100 mmHg 

PR :  80bpm 

RR : 20cpm 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema :  absent 


SYSTEMIC EXAMINATION : 


CVS :


INSPECTION: 

Shape of chest- bilaterally symmetrical 

Trachea - central 

No visible pulsations 

No scars,sinuses or dilated veins 


PALPATION :


No thrills,parastrenal heaves


AUSCULTATION : 

s1,s2 are heard 

No murmurs 

No raised jvp.


RS : BAE + 

CNS : NAD and HMF + 

P/A : Soft and Non tender  


INVESTIGATIONS: 










2D ECHO : 

USG : ABDOMEN: 



CHEST XRAY ( PA VIEW) 


NECK ( AP , LATERAL VIEW):





PROVISIONAL DIAGNOSIS : 


HYPERTENSIVE URGENCY  (DENOVO DIAGNOSED 7DAYS AGO FROM DAY OF ADMISSION) 

CERVICAL SPONDYLOSIS .



MANAGEMENT: 

T. Nicardia 20mg PO / Stat 

T. Cinod 10mg  PO /stat 

T. Telma H + T. cinod 10/40 mg PO /OD 

BP monitoring  4th hrly 

Vitals monitoring 6th hrly 

( Pt came to OPD ,his BP value recorded as 190/100 mmHg ,then Tab. NICARDIA 20 mg  given , after 30 minutes his BP value recorded as 170 /100 mmHg 

Then , Tab.CINOD 10mg  given at around 9: 20PM ,then his BP value recorded as 140/80 mmHg .


BP CHARTING: 



SOAP NOTES : 


WARD

DAY - 2 

UNIT - 3 




Stools passed 

No fever spikes 

Head ache + 


O


Patient is Conscious, Coherent , Cooperative

Temp : Afebrile 

BP : 170 /100 mmHg 

PR : 60bpm 

RR : 20cpm 

GRBS : 170 mg/dl 

CVS - S1 ,S2 + 

RS - BAE + 

CNS - NAD 

P/A - Soft and Non tender 



Hypertensive Urgency 


T. Telma H + T. Cinod 10/40 PO/OD 

T.Cinod 10mg PO /OD 

BP monitoring 4th hourly 

Vitals Monitoring 6th hourly 


WARD

DAY - 3

UNIT - 3 



Stools passed 

No fever spikes 

Head ache + 

O

Patient is Conscious, Coherent , Cooperative

Temp : Afebrile 

BP : 160 /100 mmHg 

PR : 65bpm 

RR : 20cpm 

GRBS : 170 mg/dl 

CVS - S1 ,S2 + 

RS - BAE + 

CNS - NAD 

P/A - Soft and Non tender 



Hypertensive Urgency 



T. Telma H + T. Cinod 10/40 PO/OD 

T.Cinod 10mg PO /OD 

BP monitoring 4th hourly 

Vitals Monitoring 6th hourly 

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