Monday 21 March 2016

A 50 year old man with lower and back weakness since one day ago

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016 after collecting informed patient consent (form downloadable here) by our patient-information-communication-executive from pin-code-area 736 for a discussion initiated by patient's primary care physician in-charge:

Pt. Name - acacia462nilotica
Age - 50/ man
Occ. - farmer
Add.-bhopal

Vital signs -
Tem. 98.6
Pulse-76
R.r.- 20
B.P. 110/70

C/o-
Lower limb pain
Low back pain rt. Said

Family h/o-
No family history

Personal h/o-
Nutrition -veg., tea 3/day,
Tobacco,and bidhi smoking
Nature -normal
Living Area- cloudy
Source of income 250/day
Alcohol intake before 2year

Past medi.h/0-
No past medi. History

Psychosocial h/o-
Environment h/o-
 No industrial

Objective examination

Shoulder move. Painful above 120°
Low back stiffness (lumber)
Rt. Limb move. Difficulty
nail normal
Gait normal
Posture normal

Analysis
Scissor...?

Plan
Current medi.
I/v RL - NS
Tab. B/c

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