65year old woman with C/O neck pain since 1year
28/02/2023
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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)
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