This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent


Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input
This Blog also reflects my patient-centred online learning portfolio.
Your valuable input on the comment box is welcome
 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 
Name : Arushi kumari
Roll no. 15 
Chief complaints : 
- complaint of neck pain radiating to both shoulder and hand since 2 months 
- complaint of low back pain radiating to left leg since 2 months 

HOPI:
Patient was apparently asymptomaric 2 months back then she developed back pain radiating to both upper limbslimbs which is insidious in onset and progressive in nature and then she had developed low back pain radiating to left leg which is insidious in onset and gradually progressive. 

Past History :
- K/c/o DM since 5 years on medication
Metformin 500mg OD 
- k/c/o HTN since 5 years on medication
Amlodipine 5mg
- H/o cataract surgery to left eye 3 years back 
- N/k/c/o CVA/CAD/TB/Epilepsy/Asthma 

Personal History :
Diet :mixed 
Appetite: normal 
Bowl and bladder movement: regular 
Sleep: adequate
No allergies
Addiction: nil

Family History : not relavant 

General Examination :
Patient is c/c/c.
No pallor 
No icterus 
No cyanosis 
No clubbing 
No lymphadenopathy 
No edema 
Vitals:
Afebrile
BP: 160/100 mmHg 
PR: 52 bpm
RR: 16cpm
SpO2: 99% at RA
GRBS: 342 mg%

Systemic Examination:
CVS: S1S2+,  no murmurs heard 
RS: BAE+, no added sound 
P/A: obese, soft, non tender 
CNS: No FND
Straight leg raise test: 
Rt leg - negative 
Lt leg - negative 

Clinical Images :


INVESTIGATIONS:
 PROVISIONAL DIAGNOSIS: CERVICAL SPONDYLOARTHROPATHY with k/co DM and HTN since 5 years 
Treatment:
1. INJ. HAI 6 UNITS S/C TID
2. TAB. ULTRACET /2 tab /PO/QID
3. TAB. AMLONG 5MG PO/














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