60 year old female with the complaints of neck pain and headache
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CASE
This is a case of a 60year old female with the chief complaints of -
Neck pain since 5 years and headache since 2 months
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.
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 ,she had weight loss of 10 to 15 kgs.
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.
No H/O of vomitings, loss of consciousness, shortness of breath
PAST HISTORY:-
She is known case of hypertension from past 8 years.
She had history of left thigh fracture 10 years back
No history of asthma, TB, epilepsy, any thyroid abnormalities.
PERSONAL HISTORY:- She lives in a joint family with 10 members in the family. . 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. Amlong for hypertension from 8 years.
FAMILY HISTORY:-
No similar complaints in the family.
GENERAL EXAMINATION:-
Patient is conscious, 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
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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