GM case 10

GM case
Case scenario..
 Hi,I am K.Sathpriya,3rd BDS student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning.
                    Case History 
Chief complaints 
Neck pain since 6 months,
Back pain since 6 months,
Knees pain since 6 months.
History of present illness
Patient was apparently asymptomatic 6 months ago then he had neck pain,Non radiating,no restriction of movements present.
Complaints of lower back ache since 6 months radiation to both legs with tingling sensation of bilateral legs.
Complaints of knee pain since 6 months. 
No pain abdomen,Vomitings,loose stools.
No chest pain,Palpations,SOB
History of past illness 
Not a known case of Diabetes,Hypertension,epilepsy,TB,CVA,CAD.
Surgery was done to the left eye due to trauma.
Personal History 
Diet-Mixed 
Appetite-Normal 
Bowel-Hard stools since 1 month
Micturition-Normal
Known allergies-No 
Addictions-Occasional 
Family History 
No similar complaints seen 
General examination 
Patient is conscious,coherent,Cooperative,well oriented to time,place and person.
Moderately built and nourished.
Pallor-Absent 
Icterus-Absent 
Cyanosis-Absent 
Clubbing-Absent 
Lymphadenopathy-Absent 
Oedema-Absent
Vitals 
Pulse rate-85/min
BP-140/100
SPO2-98%
Systemic examination 

Cardiovascular System 
Thrills -No
Cardiac sounds-S1S2
Cardiac murmur-No

Respiratory System 
Dyspnoea-No
Wheeze-No
Postion of Trachea-Central 
Breath sounds-Vesicular

Abdomen 
Shape of the abdomen-Scaphoid
Tenderness-No
Palpable mass-No
Hernial orifices-Normal
Free fluid-No
Bruits-No
Liver-Not palpable
Spleen-Not palpable
Bowel sounds-No
Provisional Diagnosis:Osteoarthritis 

Investigations


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