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
