Wednesday, May 22, 2024

45 Female with Neck pain,Denovo hypothyroidism,Denovo diabetes,hypertension

Saraswathi 
202337506
Cheif complaints 
A 45 uear old female came to GM opd with chief complaints of Neckpain since 10 days and low grade fever since 10 days 

Patient was resident of guntur where she lives with her parents and her 3 siblings,she is a 3rd child,Did not go to school and entered handloom work at 10years of age.
She was married at age of 15years and and by the age of 17 she had first child and after 3 years of 1st child birth she got concieved had spontaneous abortion at 6months of gestational age due to work pressure and increased stress.3 years after the second pregnancy she had 3rd child and at 3 months of age the baby died due to fever.she felt depressed at worried about that event.After 3 years from that event she gave birth to 4th child with no health issues.
Since then she is doing fine with her life.
4 years ago she had h/o generalised weakness for which she went to local hospital and diagnosed of having hypertension and started on Tab.Losartan(50mg)+Tab.Hydrochlorthiazide(12.5 mg) and after starting that medication she felt better till 2 months

She is c/o neck pain since 10 days 

2 months back then she developed neck pain insidious in onset gradually progressive and aggravated since past 10 days. 

Restriction of movements+.

Neck Pain aggravates on flexion and extension of neck.

No h/o trauma. 

Low grade fever not associated with chills and rigors since 10 days,Intermittent in nature.

No h/o sob,cough,sore throat,Abdominal pain,vomitings,loose stools, Tingling of b/l upper limbs+.

Past History :

K/c/o htn since 4 years and on medication T. losertan 50 mg+Hydrochlorothiazide 12.5 mg po/od 

N/k/c/o DM, thyroid,CVA,epilepsy, Asthma,CAD

Personal History :

Appetite -Normal
Diet -Mixed
Sleep -Adequate 
Bowel and Bladder -Normal and Regular
Addictions -None

Daily Routine:
Patient is a Weaver by occupation. She works at her own house.
She wakes up by 6 am in the morning. She has her breakfast around 8 am. Then she starts her work by 9am. She works till 1pm. Then she has her Lunch by 2pm and sleeps for an hour. She continues her work till 6pm. She then has her dinner by around 8pm and goes to sleep by 10 pm.
The Daily Routine of the patient is disturbed due to severe neck pain since 10 days.

On General examination 

Patient is concious coherent cooperative 

Well oriented to time place person 

Moderately build and nourished


No Pallor ,Icterus ,cyanosis ,clubbing , koilonychia ,lymphadenopathy

Bilateral Pedal Edema +


Vitals 


Temperature – Afebrile ( 98.6 F )

Pulse rate – 80 bpm , regular 

Respiratory rate – 16 cpm

BP – 140/90 mm Hg 

SPO2 – 98% on room air  

GRBS – 256 mg/dl


Systemic Examination:


CVS- S1 S2 heard

RS- BLAE +

P/A- Soft,NT BS+

CNS:

HMF - Intact 

Speech – Normal 

Kernigs sign - Negative 

Brudzunski sign - Negative

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

Clinical images

Hyperechoic Lesion On USG Neck






Provisional Diagnosis 
?Cervical Radiculopathy
Denovo Hypothyroidism
Denovo Diabetes Mellitus Type 2
Hypertension 

TREATMENT

1.INJ. Diclofenac Im/sos

2.T.Dolo 650 mg po/sos

3.T. Nicardia 10 mg po/sos

4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg 

5.T. vertin 8 mg po/bd 

6.T. Thyronorm 75 mcg po/od 

7.T. Metformin 500 mg po/be

8.T. Cinod 10 mg po/od

9.T. Myoril 2ml IM/BD

10.INJ. Zofer 4mg IV/SOS

11.INJ.PAN 40mg/IV/OD

12.T.PREGABA 75MG/PO/HS


Follow up on  10 oct 2023
Fbs:-106 mg/dl
Plbs:-150
Hba1c-6.7

Outcome:- goodcontrol