GENERAL MEDICINE ELOG 4

A 25 year old female came with the chief complaints of back pain since 1 year.


HISTORY OF PRESENTING ILLNESSES:

The patient was apparently asymptomatic 1 yr back then developed back pain which was severe, gradually progressive and non radiating.

The pain was aggravated on standing and relieved on rest and medication.

The pain was more during night and was associated with difficulty in breathing.


PAST HISTORY:

N/K/C/O DM, HTN, Asthma or epilepsy


FAMILY HISTORY:  not significant 


PERSONAL HISTORY:

Appetite - normal

Sleep - adequate 

Diet - mixed

Bowel and bladder movements - regular

No addictions


GENERAL EXAMINATION:

Patient was C/C/C and moderately nourished 

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal oedema


VITALS:

Temp- Afebrile

BP- 110/60 mm 

PR- 100bpm

RR- 20 cpm






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