21yr old Male, Mason

21 M mason presented with c/o pain in neck region radiating to upper back and shoulders on forward bending from past 4 yrs.

C/o swelling in the neck region from past 8yrs

HOPI-

A muscular male attributes the start of all his present complaints to a childhood incident at age of 8yrs where in he was involved in a scuffle with his neighbours with he being mugged by the opposite person.The same day he developed pain and redness which was dealt with home remedies i.e icepacks and ointment.

Later on as days passed by and he started to shoulder family responsibility after dropping out of school at age 14 the pain started to become unbearable where in it progressed to an extent that the father informs he is constantly switching jobs to suit his physical ability.

The swelling was observed by the patient himself although it hasn’t increased in size, non pulsatile and non fluid containing, attached to underlying tissue.


On examination- A well built muscular man reflecting on the labour involved in his profession, although never complained of fatigue at work. Passive flexion of neck pt is c/o pain radiating to lower back region.

 CNS- 

Reflexes - R.     L.

 Bicep.      2+.    1+

Triceps.    1+.      1+

Supinator 1+.      2+

Knee.        3+.     3+.

Ankle.       2+.      2+.

Plantar.   Flexion flexion


Power 

Upper limb

Deltoid.   4-    4-

Bicep.     4+.  4+

Triceps.  3.     3.

Extensor 

Carpi radialis. 5.  5

Flexor 

Carpi radialis. 5.  5

Abductor

pollicis longus 5.  5

Palmar interossei 5. 5


Lower limb

Iliopsoas 4+. 4+

Gluteus medius and minimus- 5.  5

Quadriceps 4+. 4+

Tibialis anterior 5.  5

Tibialis posterior 5.  5


Tone Normal 

 Vibration and proprioception - Intact


Sensory system intact 

Can appreciate fine touch and crude touch

Can sense pain


No bowel and bladder disturbances.


  

CVS - s1s2 +

Resp -NVBS


Provisional diagnosis- ?Cervical radiculopathy







SOAP notes


S :

No fresh complaints 


O :

Pt c/c/c

Temperature : 98.6 F

BP : 120/70 mm Hg

PR : 84 bpm , regular

CVS : S1 S2 +, no murmurs

RS : NVBS + , no crepts

P/A : soft, non tender

CNS: NFND


A :

? Cervical radiculopathy


P : 

1. Tab.ULTRACET 1/2 PO/QID

2. Monitor vital



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