CERVICAL SPONDYLOSIS

This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A 55 years female patient occupation by daily labour came to opd with chief complaint of neck and shoulder pain on left side since 2 years

HISTORY OF PRESENT ILLNESS :
She was asymptomatic 2 years back the she developed shoulder pain which is radiating to arm and neck 
No history of any trauma 
Aggrevates on doing work 
Relives on rest and medication 

HISTORY OF PAST ILLNESS :
No H/o DM, HTN, Asthma , epilepsy, TB . 


TREATMENT HISTORY :
History of previous medication 1year back
No history of any surgeries

PERSONAL HISTORY :
Married 
Mixed diet 
Normal appetite 
Regular bowel habit 
Micturation : normal
Sleep : adequate
Addictions : no

FAMILY HISTORY :
No significant family history 


GENERAL EXAMINATION :
Patient is conscious , coherent coperative and examined ina well lightened room
NO pallor 
No icterus 
No cynosis 
No generalized lymphadenopathy 
No clubbing 
No pedal edema 

VITALS:
Temperature-:afibrile 
pulse rate -:76/min
Resp rate -:16/min 
Bp -: 116/80


SYSTEMIC EXAMINATION :
CVS-; 
        S1,S2 HEARD 
        NO MURMERS 
        NO THRILLS 
RESPIRATORY SYSTEM-:
Inspection:
       Chest is bilaterally symmetrical
       Position of trachea -; midline
       No drooping of shoulders
       No supraclavicular hollowing or infraclavicular thickening
       Movement of the chest: bilaterally symmetrical 
        
Palpation :
       No local rose of temperature
       No tenderness
       Trachea : midline
       No intercoastal widening or crowding of ribs
        No dilated veins
       Measurement of chest expansion :
              - whole :
              - hemi :
       Vocal fremitus : 
Percussion : Rt/Lt
         Resonance sounds
         Percussion tenderness : no
Auscultation :
           Normal vesicular breath sounds
           No added sounds
           Vocal resonance : normal
ABDOMEN-:
 Inspection : 
          Shape : scaphoid 
           Flanks : free
           Umbilicus : central,inverted
           Skin : no scars,sinuses,nodules
           No dilated veins
           No visible gastric peristalsis
Palpation :
          No  Tenderness 
          No palpable mass 
          No palpable spleen and liver
Percussion :
           No fluid thrill
           No shifting dullness
           
Auscultation : 
           Bowel sounds : yes
           No bruits
CNS :
         Consious, coherent ,cooperative 
         Speech normal
         No neck stiffness
         Intact and normal
Sensory system :
        Able to percieve-:pain and temp.
Cranial nerves : normal
Motor system :  intact

PROVISIONAL DIAGNOSIS :
Cervical spondylosis 
 
INVESTIGATIONS:
Complete blood picture :
Blood grouping : A +ve
Anti HCV Antibodies - rapid : non reactive 
HBsAg - rapid : negative 
HIV 1/2 rapid test : non reactive 

Complete urine examination
Liver function tests :
Renal function tests :
ECG :
2D ECHO :
Chest X-ray :

TREATMENT:
Tab  ULTRACET
Tab   PAN
Tab SHELCAL-CT.
Tab NEUROKIND-LC 




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