A case of 21M mason







 21 M mason presented with c/o pain in neck region radiating to upper back and shoulders on forward bending from past 4 yrs.

C/o swelling in the neck region from past 8yrs

HOPI-

A muscular male attributes the start of all his present complaints to a childhood incident at age of 8yrs where in he was involved in a scuffle with his neighbours with he being mugged by the opposite person.The same day he developed pain and redness which was dealt with home remedies i.e icepacks and ointment.

Later on as days passed by and he started to shoulder family responsibility after dropping out of school at age 14 the pain started to become unbearable where in it progressed to an extent that the father informs he is constantly switching jobs to suit his physical ability.

The swelling was observed by the patient himself although it hasn’t increased in size, non pulsatile and non fluid containing, attached to underlying tissue.


On examination- A well built muscular man reflecting on the labour involved in his profession, although never complained of fatigue at work. Passive flexion of neck pt is c/o pain radiating to lower back region.

 CNS- 

Reflexes - R.     L.

 Bicep.      2+.    1+

Triceps.    1+.      1+

Supinator 1+.      2+

Knee.        3+.     3+.

Ankle.       2+.      2+.

Plantar.   Flexion flexion


Power 

Upper limb

Deltoid.   4-    4-

Bicep.     4+.  4+

Triceps.  3.     3.

Extensor 

Carpi radialis. 5.  5

Flexor 

Carpi radialis. 5.  5

Abductor

pollicis longus 5.  5

Palmar interossei 5. 5


Lower limb

Iliopsoas 4+. 4+

Gluteus medius and minimus- 5.  5

Quadriceps 4+. 4+

Tibialis anterior 5.  5

Tibialis posterior 5.  5


Tone Normal 

 Vibration and proprioception - Intact


Sensory system intact 

Can appreciate fine touch and crude touch

Can sense pain


No bowel and bladder disturbances.


  

CVS - s1s2 +

Resp -NVBS


Provisional diagnosis- ?Cervical radiculopathy







SOAP notes


S :

No fresh complaints 


O :

Pt c/c/c

Temperature : 98.6 F

BP : 120/70 mm Hg

PR : 84 bpm , regular

CVS : S1 S2 +, no murmurs

RS : NVBS + , no crepts

P/A : soft, non tender

CNS: NFND


A :

? Cervical radiculopathy


P : 

1. Tab.ULTRACET 1/2 PO/QID

2. Monitor vital




Comments

Post a Comment

Popular posts from this blog

Bi Monthly Exam May 2021

Image
Below is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 1)Pulmonology  A) Link to patient details: https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html . Questions 1:  What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Answer:  The following is the event timeline of symptom occurrences in the patient:  1st episode of SOB 20 years ago was of Grade 2. Lasted one week. Relieved on medication  Next 8 years, similar events every January which lasted 1 week, grade 2 severity. Relieved on medication  Was diagnosed with Diabetes 18 years ago  2nd severe episode of SOB 12 years ago and was of grade 2 type. Lasted 20 days. Relieved on hospitalization and treatment Next 12 years, each SOB incident star
Read more

Bi monthly exam Dec 16

Image
  This is my submission for the Bimonthly internal assessment for the month of November." Most of the information here have been collected from different reference sites, the links to which have been mentioned. The points copy pasted have been put in quotes.  The questions to the cases being discussed can be viewed from the link below 👇 https://medicinedepartment.blogspot.com/2020/12/medicine-question-paper-for-december.html?m=1 1) A 55 year old man with Recurrent Focal Seizures Detailed patient case report here:  http://ushaindurthi. blogspot.com/2020/11/55-year- old-male-with-complaints-of. html 1. What is the problem representation of this patient and what could be the anatomical site of lesion ? Ans :  55 year old man presented to the casualty with the complaints of Unable to move his right upper limb he suddenly started complaining that he couldn’t move his right upper limb few minutes later he developed a sudden onset, tonic clonic seizures involving his right upper limb an
Read more

Academic Presentations

Image
1)INTERPRETATION OF PERICARDIAL FLUID ANALYSIS Use of light’s criteria in interpreting pericardial fluid is irrational as going by the study being provided here where in 30 patients with no pericardial disease undergoing CABG and Valve replacement surgery were analysed. The mean fluid LDH was 2.4times higher than sr LDH And mean fluid protein 0.6 times lower than Sr protein. The avg leucocyte count was found to be more than 1400… In the application of light’s criteria these might have been labelled as exudative causes. Hence light’s criteria has poor diagnostic value for pericardial fluid 1) CRITICAL APPRAISAL OF COVID 19 Treatment Drugs and Interventions Discussion of RECOVERY trial, ACTT-1 trial and COVACTA trial. 2)  ACCURACY OF ACTH STIMULATION IN DIAGNOSING ADRENAL INSUFFICIENCY 102 patients included in the study Out of which 66 patients showed a normal response to ACTH stimulation, with peak cortisol levels greater than 500 nmol/L (18 µg/dL). We considered them as responders (Gro
Read more