70Y old suffering from Neck pain and back pain. (CKD)

4th July 2023

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 70-year-old male, resident of Tirumalagiri, and Farmer by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.

This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

-Neck pain and Back pain since 10 days. 

History of present illness:- 

Pt was apparently asymptomatic 10 days back. The onset of neck pain was of gradual onset, dragging type and localised to the neck region. The patient had lower back pain later, with gradual onset, dragging type and localised to the lower back region. The pain remains consistent since admission. The pain gets aggrevated when the patient attempts to get up and there are no apparent relieving factors. 

History of past illness:-

The patient has DM since 24 years and HTN since 10 years. 

The patient does not have any history of TB, Epilepsy, and asthma.

Surgical history

Patient was apparently asymptomatic 8 years ago. Afterwhich the patient developed stomach pain which was later diagnosed to be cholelithiasis. The patient had undergone cholectomy. Later it was also found that the patient has CKD. 

The patient has been undergoing dialysis since 4 months, with a frequency of 2-3 times per week. 

The patient has undergone blood transfusion three months back. 

Personal history:-

Water intake:- half a litre per day

Appetite:- reduced

Diet:- mixed 

Bowel movement:- normal

Bladder movement:- normal

Alcohol:- occational consumtion for thirty years. 

Smoking:- nil

Addiction:- nil

Allergies:- nil

Exercise status:- moderate

FAMILY HISTORY:-

- not significant. 

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

No Palor

No Icterus

No Cyanosis

No Clubbing 

No Pedal edema

No Significant lymphadenopathy

CLINICAL PICTURES:-

REPORTS:-