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50 yrs male presented with severe pain over neck and back.

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.


The patient got in touch with our college for help and I tried to interview him and collect the data that would be useful to our Medicine department Team to help understand his requirements.

CASE: A 50 yrs male presented with severe pain over neck and back.

CHIEF COMPLAINTS

Severe pain in back and neck

Reduced neck mobility 

HISTORY OF PRESENTING ILLNESS

Increased frequency of urination

Increase urine outflow 

Burning micturition 

On 1st January , 2019 patient underwent surgery for BLADDER OUTLET OBSTRUCTION

due to large median lobe of the prostate trabeculating the bladder wall

Surgery: Bilateral Transurethral resection of Prostate (TURP) 

Cystoscopy done on 1st January ‘19

Foleys catheter removed on 3 January ‘19

Consulted a general surgeon for the removal of foleys catheter in Kolkata. Removed w/o any complication and was on some medication (prescription attached)

Patient was doing fine then he developed severe pain in back and neck without fever for the past 4-5 months.

The patient consulted a local practitioner on 25th May , 2021 and he’s advised for cervical spine X-ray (AP and Lateral).

IMPRESSION : Reverse Lordosis (report is attached below)

Decreased intervertebral disc space between C5 and C6 and diagnosed with Spasmodic Torticolis










PAST HISTORY 


TREATMENT HISTORY

Tab Brufen (400mg)

Cap Miofree (4mg)

Tab Aciloc RD

Cap Nervemax Active / Meganeuron OD plus

Tab Sungaba 

Tab Neurobion Forte

Tab Rantac

Tab Zerodol MR

Tab Tenxit plus 

Physiotherapy treatment



PERSONAL HISTORY

Occupation: Driver

Diet: mixed

Sleep: reduced

Bowel and bladder movements : regular 

History of smoking



FAMILY HISTORY

Patient’s father had history of profuse bleeding on cut (? Haemophilia)


ALLERGIC HISTORY

No history of allergy


VACCINATION HISTORY

Covaxin administered on 11 May , 2021 


GENERAL EXAMINATION 

Pallor:

Icterus:

Cyanosis:

Clubbing:

Lymphadenopathy:

Edema:

VITALS

Temperature: 

PR:

BP:

Respiratory rate:

SpO2:

Blood Sugar:


SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION 


INSPECTION

Shape:

PALPATION

PERCUSSION

AUSCULTATION


CARDIOVASCULAR SYSTEM EXAMINATION



RESPIRATORY EXAMINATION



CENTRAL NERVOUS SYSTEM EXAMINATION



INVESTIGATION

TURP Chips: Benign Prostatic Hyperplasia (BPH)







Updates on 4th August , 2021

Pain reduced after taking the medication

Pain occurs after continuous sitting and when he stands up

No pain felt while walking or moving limbs 

Right side pain is more prevalent 

Not a continuous type of pain 

No pain in abdomen 

No difficulty in respiration

Updates on 24th September , 2021

Pain was subsided but it again appeared , radiating towards the leg

Constant back pain 


DISCHARGE SUMMARY 


























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