A 60 year old female with Neck pain

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CASE

This is a case of a 60year old female with the chief complaints of - 

Neck pain and headache since 5 years 

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 10 years ago. She then complained of back pain which is insidious in onset and gradually progressive. There are no aggravating or relieving factors. She then developed a head injury due to a heavy object (bottle gourd) falling on her head.

5 years ago she developed fever which was associated with pain in multiple joints and was diagnosed with Chikungunya. Following the episode the joint pains persisted and the patient complained of pain in multiple joints which started in the fingers and wrist and progressed to all the joints. The pain in the joints is greater when she wakes up and is associated with stiffness. The stiffness is relieved on activity. 

Her neck pain also started around 5 years ago and is associated with pain in the right nuchal and occipital region and the right shoulder. The pain is temporarily relieved on using topical and oral analgesics. 

2 years ago she visited the hospital due to an episode of fever and was incidentally diagnosed with Diabetes. She also complained of weight loss in the last 2 years around 10 to15kg.

1 year back she couldn’t raise her right arm and had increased severity of back pain for which she was advised MRI and she was informed about spine degeneration. Due to limitation of movement she was given injection to her right shoulder joint and after 10 days followed by injection to knee joint.

Patient now presented with increased severity of headache and neck pain which is 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.

There is 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 daughters in law. She used to work as a daily wage worker but from past 4 years she is not working due to the pain and discomfort.

She daily cooks for her family members.

Her sleep is inadequate due to pain and discomfort. She sleeps at 1am at night and wakes up at 4am in the morning.

She mainly consumes vegetarian food, which mainly includes millets, chapatis and any veg curries.

Her appetite is normal.

Her bowel and bladder movements are regular.

She used to consume toddy and alcohol but stopped 2 years ago.

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 Diabetes from past 2 years.

FAMILY HISTORY:- 

No similar complaints in the family.

GENERAL EXAMINATION:- 

Patient is conscious, coherent, cooperative and well oriented to time, place and person

Moderately built and moderately nourished.

Vitals :- 

Temp - afebrile

BP  - 130/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 

Pallor - present 

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

SYSTEMATIC EXAMINATION:-

1) CVS examination:-

- S1 S2 heard

- no murmurs heard.

2) Abdominal examination:- 

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

Bowel sounds heard

3) Respiratory examination :- 

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant on percussion

- Bilateral equal air entry, no added sounds heard.

4)  CNS examination :- 

- No focal neurological defects

- All cranial neves are intact. 

- No meninges signs 

Glasgow scale- 15/15

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 

PROVISIONAL DIAGNOSIS:-  

Neck pain under evaluation, could be due to rheumatoid arthritis?

with Diabetes type II and Hypertension

INVESTIGATIONS 

Blood urea:- 

CRP:- 

Complete urine examination:- 

Hemogram:- 

LFT:-

Serum creatinine:- 

Serum electrolytes:- 

HIV:- 

Hepatitis B :- 

Hepatitis C:- 

TREATMENT:-

Strict diabetic diet 

Tab. ULTRACET 1/2 tab PO/ QID

Tab. SULFASALAZINE 1gm PO/ OD

Tab. METFORMIN 500mg PO/ OD

Tab. LOSACURE 50 PO/ OD