A 60 YEAR OLD FEMALE CAME TO OPD WITH HEADACHE AND NECK PAIN SINCE 5 YEARS
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CHIEF COMPLAINTS:-
Headache and neck pain since 5 years.
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 10 years back then she developed fever which was associated with pain and swelling of joints, she went to hospital and was diagnosed with chikungunya, initially pain it was in fingers and wrist and gradually progressed to all joints. It is associated with morning stiffness of all joints, stiffness relived on activity and there is also difficulty in movement of joints.
10 years back she had an head injury due to fall of bottle guard on her head and not associated with dizziness, headache, bleeding.
2 years back she had fever and went to hospital for checkup, there she was diagnosed with diabetes and it is associated with weight loss of 10 to 15 kgs.
1 year back she couldn’t raise her arms and had severe back pain she was advised MRI and she was informed about having spine degeneration. Due to limitation of movements she was given injection to shoulder joint and after 10 days followed by injection to knee joint.
Patient now presented with severe headache in the occipital region and neck pain since 5 years and pain radiating to right shoulder. It is associated with difficulty in moving head from side to side, pain on moving head and there is presence of heaviness in head.
No history of fall, fever, vomiting and shortness of breath.
PAST HISTORY:-
She is known case of hypertension from past 20 years.
Diabetes mellitus from past 2 years.
She had hysterectomy 30 years ago.
No history of asthma, TB, epilepsy, any thyroid abnormalities.
PERSONAL HISTORY:- ( daily routine )
She lives in a joint family with 10 members in the family. She live with her husband along with her 3 sons and her daughter in law. She used to work as a daily wage worker for agriculture but from past 4 years she is not working.
She usually cooks for her family members.
Her sleep is inadequate due to pain . She usually sleeps at 1am at night and wakes up at 4am in the morning.
She only consumes vegetarian food, which mainly includes millets, chapatis and all veg curries.
Her appetite is normal.
Her bowel and bladder movements are regular.
She used to consume alcohol but stopped from past 2 years.
She consumes tobacco daily to relieve her tooth pain from past 3 years.
She has no known allergies.
TREATMENT HISTORY:-
She consumes tab. Losartan + hydrochlorthiazide for hypertension from past 20 years.
Tab. Metformin for DM form past 2 years.
Power:-
Rt UL-5/5. Lt UL-5/5
Rt LL-5/5. Lt LL-5/5
Tone:-
Rt UL -N
Lt UL-N
Rt LL-N
Lt LL-N
Reflexes: Right Left.
Biceps. ++. ++
Triceps. ++ ++
Supinator. + +
Knee. ++ ++
Ankle. + +
Plantar: Flexion Flexion
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