Ashutosh Raut

C/c - back pain since past 3 months  HOPI - The pain is insidious in onset ,throbbing type of pain , aggreviates on walking ,no relieving factors , associated with neck pain , headache and throat pain  Past history - k/c/o renal stones since 6 months currently not on medication No h/o asthma , epilepsy, htn , tb , DM ,CAD  No h/o past surgeries  No known allergies  Personal history -sleep is adequate ,diet is mixed appetite is normal ,bowel and bladder movements are regular ,no addictions Family history - not significant Vitals -  Temp - afebrile  BP - 120/80 mm Hg  PR- 80 bpm RR- 12 cycles/ min General examination Patient is concious coherent and cooperative. Moderately built and nourished. No signs of pallor icterus clubbing cyanosis lymphadenopathy oedema.

Chief complaint generalised body pain from past 15 days associated with headache  History of present illness - pain insidious in onset ,gradually progressive ,aggreviates on work , relieves for sometime after resting . It is associated with palpitations and fever . No h/o nausea vomitting giddiness or blurring of vision  Past history  N/k/c/o - DM,HTN, epilepsy ,asthma ,CAD  Personal history -sleep is adequate,diet is mixed , appetite is lost ,bowel and bladder movements are regular ,addictions -occasional drinker  Family history -  nil significance Vitals  TEMP - afebrile PR- 88 bpm BP- 130/80 mm of Hg RS - 15 cycles / min  General examination Patient is concious coherent and cooperative. He is moderately built and nourished. No signs of pallor icterus clubbing cyanosis lymphadenopathy oedema. Cystemic examination CVS  S1 S2 heard  No abnormal sounds  RS No additional sounds heard