CERVICAL SPONDYLOSIS

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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