65 year old male with abdominal pain& neck stiffness

65 year old male agricultural labourer with abdominal pain& neck stiffness

July 24, 2023

Chief complaints
Abdominal pain since 1 year
Neck pain with stiffness since 1 year
Lower back pain radiating bilaterally to lower limbs 
History of Present Illness
Patient was apparently asymptomatic 4years ago then he had H/O trauma (he had fallen while taking his cattle to the field) of right hip and hemianthroplasty was done then he started having neck pain since 1yr and radiation to bilateral upper limb which is insidious in onset gradually progressed to current stage
Difficulty in flexion and extension of neck and tingling sensation of bilateral upper limbs
Patient gradually developed lower backache pain which is dragging type of pain radiating to lower limbs since 1year
Patient also complaints difficulty in bending, difficulty in getting up from sitting position,joint stiffness abdomen pain and bloating and belching
He also complains of loss of Appetite and passage of hard stools since 3months
Negative history - No Malena, constipation, vomiting ,sob,chest pain, cough,fever

Past history
Not a k/c/o HTN, DM,CVA,CAD,TB, Epilepsy,Asthma

Treatment history
Hemianthroplasty of right hip 4yrs ago

Personal history 
Married
Agriculture labour
Loss of appetite
Mixed diet
Normal micturition 
No known allergies
Addictions - occasional(stopped 5months ago)

Family history
Not significant 

General examination 
Patient is concious, coherent and cooperative 
No pallor,icterus,clubbing of fingers, lymphadenopathy,cyanosis and edema

Vitals
Temperature-Afebrile 
Pulse rate-68/min
Respiratory rate-16/min
Bliod Pressure-130/70mmhg
SPO2-98%

Systemic examination
Cardiovascular System:
-No thrills
-Cardiac sounds S1 & S2 heard
-No cardiac murmurs
Respiratory System:
No dyspnea 
No wheezing
Central trachea
Vesicular breath sounds
Abdomen:
Obese shaped abdomen 
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds-yes
CNS:
Patient was conscious
Normal speech
Neck stiffness present 
Investigations
2D ECHO
ECG















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