NEW ADMISSION ON 2-19-2020.

• GENERAL DATA.
• PX-TR
• AGE- 49.
• FEMAL
• MARRIED
• ROMAN CATHOLIC.
• CHIFE COMPLAIN.
• SPINE PAIN
• HPI.
• 5 YEARS PTA PX WAS SLEEPED AND HE GOT STIFFNESS IN THE
NECK .PX WENT TO MASSAGE CENTER AND PAIN WAS
RELIEVED. NO CONSULT DONE .
• 3 YEARS PTA PX HAD CONSULT AT GMH (BOHOL )AND WAS
PRESCRIBED PAIN RELIEVER AND PATIENT WAS GOWING
THERE EVERY YEAR AND PAIN RELIVED WAS GIVEN .
• 2 MONTH PRA PX WENT TO CDH FOR CONSULTATION TO
NEUROLOGIC AND WAS ADVISED MRI AND GIVEN
MEDICATION
• HE WAS REFERRED TO DR TAN FOR ANOTHER
CONSULTATION AND HE ADVISED TO UNDER GONE
2WK PHYSICAL THERAPY BUT NO IMPROVEMENT.
• PATIENT WAS ADMITTED ON JAN 15 2020 FOR LOSS OF
APPETITE.AND ADVISED FOR WHOLE ABDOMINAL
ULTRASOUND, AND LABORATORY.
• BUT STILL NO IMPROVEMENT THUS PX WAS
TRANSFERRED TO OUR INSTITUTION.
• MRL IMPRESSION :DEFORMITY OF THE DENS AND ANTERIOR ARCH
OF THE ATLAS . THE SUSPICIOUS OBLIQUE DEFECT MAKE A CHRONIC
POST TRAUMATIC ETIOLOGY SUSPECT .
• ADDITIONAL FINDINGS OF ANTERIOR BRIDGING OSTEOPHYTES C3 TO
C6 LEVEL MAY MAKE AN UNDERLYING INFLAMMATORY
SPPONDYOLARTHROPATHY SUSPECT .
• ADDITIONAL IMAGING OF THE WHOLE APINE WITH FOCUSED
SECTIONS TO ATLANTO-AXIAL JOINT ARE SUGGESTED.
• MILD TO MODERATE CENTRAL AND LATERAL SPINE VANSL STENOSIS
AT C3-C4 TO C5-C6 DUE RO NARROWING BY POSTEROLATERAL
ENDPLATE OSTEOPHYTES AT THESE ELVES .
• DEGENERATIVE DISC DISEASE WITH C3-C4 DISC BULGE .
• NO DEMONSTRABLE ABNORMALITIES INTRINSIC TO THE
CERVICAL CORD OR CERVICOMEDULLARY JUNCTION .
• WHOLE ABDOMINAL ULTRASOUND.
• MILD FATTY LIVER .
• RIGHT RINAL CYST..
• CONTRACTED URINARY BLADDER.
• NORMAL GALLBLADDER ,COMMON BILE DUCT , PANCREAS,
SPLEEN AND LEFT KIDNEY ULTRASONICALLY.
• NORMAL SIZE PROSTATE GLAND .
• CT-SCAN.
• HYPERTRO DEGENERATIVE CHANGES OF THE CERVICAL SPINE
WITH OSSIFICATION OF THE POSTERIOR LONGITUDINAL
LIGAMENT.
• MRI OF THE CERVICAL SPINE IS SUGGESTED FOR FURTHER
EVALUATION OF THE DISC SPACES IF WARRANTED .
• STRAIGHTENED CERVICAL LORDOSIS LIKELY DUE TO MUSCLE
SPASM .
• ELECTROLIGHTS.
• SODIUM- 137. MMOL/L
• POTASSIUM- 3.65 MMOL/L.
• PAST MEDICAL HISTORIES
• NO MEDICAL ILLNESSES.
• NO MENTANANCE MEDICATION.
• NO FOOD OR DRUG ALLERGY
• NO SURGICAL INTERVENTION
• HOSPITALISED JAN 15 2020 FOR LOSS OF
APPETITE.
• PERSONAL AND SOCIAL HISTORY.
• (+) SMOKER.
• (-) ALCOHOLIC.
• REVIEW OF SYSTEM.
• GENERAL: ( - ) WEIGHT LOSS ,( - ) FEVER , (+) LOSS OF APPETITE
• SKIN : ( - ) RASHES, ( - ) CHANGE IN COLOR, ( - ) ITCHING.
• HEENT: ( - ) HEADACHE, ( - ) BLURRED VISION ,( - ) HEARING LOSS
• ( - ) DISCHARG. ( - ) NASAL STUFFINESS, ( - ) DISCHARGE
• ( - ) COLD , ( - ) TONSILOCONGESTION .
• NECK: ( - ) SWOLLEN GLANDS, ( -) PAIN, ( - )STIFFNESS IN THE NECK.
• RESPIRATORY : ( - )COUGH, ( - ) DYSPNEA.
• CARDIOVASCULAR: ( - )CHAT PAIN,( - ) PALPITATION
• GASTROINTESTINAL: (+) ABDOMINAL PAIN, ( -) VOMITING,(
- ) DIARRHOEA ( - ) SWALLOWING PROBLEM .NO CHANGE
IN URINE COLOR
• MUSCULOSKELETAL: ( - ) JOINT PAIN,( +) SHOULDER PAIN .
• PE.
• GENERL-AWAKE,ALERT , NOT IN RESPIRATORY DISTRESS.
• VITAL SIGN –BP-110/80,HR-78,RR-18,TEM -36.4,O2SET-98%.
• SKIN-NO RASHES , NO LESTION , WARM TO TOUCH, GOOD
SKIN TUGOR .
• HEENT- ATRUMATIC ,NO DISCHARGE FROM EYES ,EARS ,
NOSE ,NO TONSILO CONGESTION.
• CHEST AND LUNG – EQUALS CHEST EXPANSION,CLEAR BREATH SOUND .
• CVS – ADYNAMIC PRICORDIUM, DISTINCT HEART SOUND, NO MURMUR.
• ABDOMEN- GLOBULAR, NABS, NO ORGANOMEGALY , (-) TENDERNESS NOTED
• EXTREMITIES– NO CYANOSIS , NO EDEMA , CRT LESS THAN 2SEC.
• NEUROLOGIC HISTORY.
• GENERAL - ALERT ,
• CN:INTACT .
• MOTOR STRENGTH-5/5 ALL EXTREMITIES.
• ADMITTING DIAGNOSIS.
• HERNIATED DISC C3 – C4.
THANK YOU…