GENERAL MEDICINE CASE PRESENTATION 


CASE SCENARIO 

A male 55 years old patient farmer by occupation came to opd with chief complaints of numbness of hands, knee pains, tremors 

HISTORY OF PRESENT ILLNESS 

Numbness of hands and and nerve weakness,pain in the knee since 10 years 

 HISTORY OF PAST ILLNESS 

Pt was met with an accident 10 years back resulting in cervical spinal injury 

TREATMENT HISTORY 

Pt is on pain medication since 10 years 


PERSONAL HISTORY 

Irregular bowel habit 
Normal bladder movement 
Mixed diet 
Non smoker 
Non alcoholic 

PHYSICAL EXAMINATION 


.patient is conscious,coherent ,and cooperative 


.moderately built and moderately nourished 


.No signs of --pallor 


                         .icterus


                          .clubbing


                          .cynosis


    .no edema present 

   .no lymphadenopathy 

  .  VITALS

  .Temperature-:98.4F

  .pulse rate     -:86

  .Rp                   -:20/min

  .Bp                    -:120/80mm/Hg

  .spo2                 -:96



SYSTEMIC EXAMINATION-:



CARDIOVASCULAR SYSTEM 

       .S1 S2 HEARD

       .No murmers


RESPIRATORY SYSTEM 


.Position of trachea is central 

.breath sounds -normal vesicular breath sounds 



ABDOMEN 


.Shape- scaphoid 

.no tenderness

.no palpable mass

.no free fluid 



.spleen and liver not palpable 


CENTRAL NERVOUS SYSTEM 


.Intact 

.no focal defects 

.no abnormality detected 


CLINICAL IMAGES 


   







            



   



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