60Y F CAME TO CASUALTY WITH C/O BURNING SENSATION ALL OVER BODY AND HEADACHE SINCE 6 MONTHS

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 C/O BURNING SENSATION ALL OVER BODY SINCE 6 MONTHS

 C/O HEADACHE SINCE 6 MONTHS

HOPI:

PT WAS  APPARENTLY ASYMPTOMATIC 6 MONTHS BACK THEN SHE DEVELOPED BURNING SENSATION NALL OVER THE BODY INSIDIOUS IN ONSET ASSOCIATED WITH TINGLING AND NUMBNESS OF BOTH UPPER AND LOWER LIMBS.

C/O HEADACHE SINCE 6 MONTHS IN FRONTAL AREA, INSIDIOUS ONSET AND ASSOCIATED WITH GIDDINESS, PHONOPHOBIA, PHOTOPHOBIA.

NO H/O NAUSEA, VOMITING.

H/O NECK PAIN PRESENT AND LOWER BACKACHE PRESENT.

PAST H/O:

K/C/O HTN SINCE 2 YRS AND USED MEDICATION FOR 2 MONTHS AND STOPPED.

NOT A K/C/O DM, TB, ASTHMA, EPILEPSY, CVA, CAD, THYROID DISORDERS

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER: REGULAR

ADDICTIONS: NIL

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:150/80 MM HG

PR:88 BPM

RR:18CPM

SPO2: 98%

GRBS- 99 MG/DL

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

INVESTIGATIONS;

HEMOGRAM:

HB- 13.6

TLC- 6400

PLTS- 1.40

POST LUNCH BLOOD SUGAR 24-01-2024 05:05:PM 146 mg/dl 140-0 mg/dl

RFT 24-01-2024 05:05:PM

UREA 18 mg/dl 42-12 mg/dl

CREATININE 0.8 mg/dl 1.1-0.6 mg/dl

URIC ACID 2.0 mg/dl 6-2.6 mg/dl

CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 3.5 mg/dl 4.5-2.5 mg/dl

SODIUM 141 mEq/L 145-136 mEq/L

POTASSIUM 4.4 mEq/L 5.1-3.5 mEq/L

CHLORIDE 105 mEq/L 98-107 mEq/L

LIVER FUNCTION TEST (LFT) 24-01-2024 05:05:PM

Total Bilurubin 0.77 mg/dl 1-0 mg/dl

Direct Bilurubin 0.20 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 24 IU/L 31-0 IU/L

SGPT(ALT) 10 IU/L 34-0 IU/L

ALKALINE PHOSPHATE 154 IU/L 141-53 IU/L

TOTAL PROTEINS 7.6 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.4 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.38

COMPLETE URINE EXAMINATION (CUE) 24-01-2024 05:05:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 1-2

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

HBsAg-RAPID 24-01-2024 05:05:PM Negative

Anti HCV Antibodies - RAPID 24-01-2024 05:05:PM Non Reactive

DX: HYPERTENSION

CERVICAL SPONDYLOSIS

TREATMENT:

TAB. NAPROXEN  250 MG PO/ BD 1--0--1

TAB. PREGABA-NT 75/10 MG PO OD H/S 0--0--1

TAB. NEUROBION FORTE PO OD 0--1--0

TAB. VERTIN 8 MG PO /TID 1--1--1

SYP. ASCORYL 10 ML PO /TID 1--1--1

CERVICAL SOFT COLLAR