65year old woman with C/O neck pain since 1year

 28/02/2023

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: K. Thanmai(intern)


A 65 year old female came with chief c/o neckpain since 1 year

Tingling sensation of b/l upper limbs since 5 months

Reeling sensation since 10 days  

HOPI:

Patient was apparently asymptomatic 1 year back then she developed reeling sensation and headache for which she went to local hospital and diagnosed as having high blood pressure.

3 days back she went for regular health checkup and was found to have high blood sugar levels(grbs-349 mg/dl).

No polyuria

No polydypsia

No loss of weight 

No loss of apettite 

No delayed wound healing 

No burning micturition 

No frothing of urine 

Tingling sensation of both upper limbs present 

No loss of sensation 

No numbness

Neck pain since 1 year,dull aching pain radiating to shoulders

Restriction of movements present 

Pain aggrevates on flexion of neck.

No h/o Fever 

No h/o joint stiffness,swelling of joints

PAST HISTORY:

K/c/o htn since 1 yr 

On T.telma 40 

N/K/C/O CVA,CAD,TB,EPILEPSY

MENSTRUAL HISTORY:

Attained menopause at the age of 45years

PERSONAL HISTORY:

occupation: farmer

appetite :normal 

diet non veg 

bowel and bladder movements normal

no addictions 

FAMILY HISTORY: insignificant

GENERAL EXAMINATION:

patient is conscious cooperative coherent well oriented to time place person 

no pallor , icterus, cyanosis, clubbing , lymphadenopathy, edema 







VITALS :

temperature : 98 F

PR: 76

RR:16cpm 

BP 120/80mmhg 

spo2: 98 at room air 

SYSTEMIC EXAMINATION :

CVS :S1S2 heard no cardiac murmurs heard 

RS :NAD NVBS heard 

P/A Soft and non tender scaphoid abdomen 

CNS : 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 


MOTOR SYSTEM:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right  Left

Biceps      ++        ++

Triceps.   ++.        ++

Supinator  +        +

Knee.         ++.      ++

Ankle        ++.       ++

SPINOTHALAMIC:   

                                   Right   Left

Crude: UL:                 N          N

 touch  LL:                 N           N

Pain.    UL:                 N          N

              LL:                 N          N

POST.COLUMN:

Fine:.    UL:                N          N

 touch   LL:                N           N

Vibrations  :                    

Upper limb  

 Acromian  :            10sec      9.8sec

Olecranon :             8 sec        9sec

Lower limb   :

Knee       :                11.75 sec   10.65sec

Malleolus :            11.42 sec   10.20 sec

Position sense:

 Upper limb:              10/10       10/10

Lower limb:.              10/10       10/10


RHOMBERG'S : Negative


CORTICAL: 

Tactile localisation:

Upper limb               Normal       Normal

Lower limb               Normal      Normal


Graphesthesia :            

Upper limb               Normal       Normal

Lower limb               Normal      Normal


Stereognosis:     

 Upper limb               present      present


Investigations :

HEMOGRAM:

Hb:11.5gm%

TLC:10,300 cells/cumm

PLATELET COUNT: 3.3 laks/cumm

CUE:

ALBUMIN: TRACE

SUGARS: NIL

SE .UREA: 14mg/dl

SE. CREATININE: 0.7mg/dl

SODIUM: 140mEq/l

POTASSIUM:3.5mEq/l

CHLORIDE:105 mEq/l

RBS:129mg/dl

FBS(28/02/2023):76 mg/dl

FBS(01/03/2023): 84 mg/dl

HbA1c: 6.4%

LFT:

TB:0.93 mg/dl

DB:0.19 mg/dl

AKP:192 IU/L

TP:6.9 mg/dl

ALBUMIN:4.28 mg/dl

A/G ratio:1.63

SEROLOGY: Negative

X-Ray C- Spine(LATERAL AND AP VIEW)






ECG:(28/02/2023)




2D ECHO:(28/02/2023)

EF:65%
TRIVIAL AR,No MR/TR
NO RMWA,NO AS/MS
SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION

USG ABDOMEN AND PELVIS:

 No sonological abnormalities seen.


PROVISIONAL DIAGNOSIS:

Cervical Spondylosis

COURSE IN THE HOSPITAL:

ORTHOPEDICS OPINION TAKEN I/V/O NECK PAIN SINCE 1YEAR:(28/02/2023)
X-RAY C-SPINE (AP,LATERAL VIEW)
IMPRESSION: DEGENERATIVE CHANGES NOTED
ADVISED:
  1) Tab. ULTRACET PO/QID
  2) Tab. PAN 40MG
  3) IFT NECK PHYSIOTHERAPY
  4) CERVICAL STRENGTHENING EXCERCISES
 
OPHTHAL OPINION TAKEN I/V/O ANY HYPERTENSIVE RETINOPATHY CHANGES:(28/02/2023)
IMPRESSION:
Anterior segments and fundus are in normal limits. No hypertensive retinopathy changes noted


TREATMENT GIVEN:

On DOA:(27/02/2023)
Tab.ULTRACET PO/QID

ON (28/02/2023)
TAB.ULTRACET PO/QID
TAB.PAN 40MG PO/BBF
CERVICAL STRENGTHENING EXERCISES
IFT NECK PHYSIOTHERAPY 

ON (01/03/2023)
TAB.ULTRACET PO/QID
TAB.PAN 40MG PO/BBF
CERVICAL STRENGTHENING EXERCISES
IFT NECK PHYSIOTHERAPY 

Advised for Dietary modifications
















Comments

Popular posts from this blog

50yr old M with c/o sob and cough since 15days

50 yr old M with c/o SOB since 10days

20year old lady with c/o difficulty in breathing since 20days