A 46 year old woman with pain on the right side of the neck and the right upper arm
A 46 year old woman, from Hyderabad, who is a homemaker, came with the chief complaint of a sharp, stabbing pain on the right side of the neck and right upper arm which has worsened since 1 week.
Active learning discussion following the case :
History of presenting illness :
- The patient was apparently asymptomatic 8 years ago when she felt pain (on and off) in the right side of the neck radiating to the right shoulder and right upper arm.
- The pain has gradually progressed in severity over the past 1 week after performing neck flexes while doing yoga, when she felt a sudden, sharp, stabbing pain in the right side of the neck radiating to the right shoulder and right upper arm.
- The pain is described to be of a severity of 4/10.
- The pain is aggravated on lifting weight from the floor. It relieves on lying down but not completely.
The pain does not relieve on medication.
Activities of daily living :
- From the year 2002 to 2008, the patient would wake up at 6:00 AM each day and begin her regular household activities at 6:30 AM, beginning with cooking for 15 of her family members as she lived in a joint family.
- After cooking till 9:00 AM, she would then serve breakfast to everyone, following which she would eat breakfast and clean all the cooking utensils.
- Then, she would sweep and wipe the floor, clean the 2 storied-house they were living in. She would wash all the clothes by hand, and dry them.
- This whole routine took almost 5 hours. At 3 pm, she would finally get a break of about 15 minutes, immediately after which she would have to prepare tea and snacks for the family. She would then begin to cook dinner (making Chapattis, Curry, etc) and by the time she would be done with eating dinner, washing the kitchen utensils and setting up for the next day, it would be 11:00 PM. She would go to sleep at 11:00 PM.
- Currently, the patient has moved out of her in-laws place and lives with her husband and two children.
- She has discontinued cooking because of her pain. She continues to rest.
- She is able to perform activities such as grooming (combing her hair), personal hygiene (brushing her teeth and taking a bath) , dressing, and eating since the past 1-2 days.
Range of Movements :
- She is able to move her perform flexion, extension, adduction, abduction and circumduction of the shoulder joint, inspite of the pain.
Psychosocial history :
- Not significant
- No history of trauma,
- No history of pain or swelling in other joints.
Past history :
- No history of similar attacks in the past.
- No history of Diabetes Mellitus, Hypertension, Tuberculosis, Asthma, Thyroid disorders, Epilepsy, CAD.
Treatment history :
- The patient has been using medication (images attached below) since the past 1 week.
- She went to physiotherapy for 3 days, but discontinued it because there was no improvement in the pain.
Personal History :
- Diet : Mixed
- Appetite : Normal
- Sleep : Inadequate due to severe pain.
- The patient cries of pain at night causing disturbed sleep.
- Bowel and bladder movements : Regular
- No habits (non-smoker, non-alcoholic)
Family history :
- Her sister has similar complaints.
Menstrual history :
- Age of menarche - 15 years
- Cycle - 5/30 days,
- She uses 4 pads a day
- No history of cramps or clots
Images of the MRI scan and report are attached below :
[1/29, 8:01 PM] Post-residency PG 1:Very well done history. The patient would be proud of you. 👍
Because of your well done history I am even able to visualize the diagnosis with confidence.
I feel her diagnosis is Repetitive Strain Injury (RSI) and it will need a multidimensional approach
What were her daily activities before 2002? Was there a drastic change in her ADL from 2002?
[1/29, 8:10 PM] MBBS UG Student 1: Before 2002, she was into stitching business where she was stitching teddy bears and sewing sequins. She also performed her daily household work.
[1/29, 8:11 PM] Post-residency PG 1: So did her work increase or reduce after 2002?
How long was she regularly stitching before 2002?
[1/29, 8:13 PM] MBBS UG Student 1: It increased after 2002.
She was regularly stitching for about 4 years before 2002, from 2PM to 8PM everyday.
[1/29, 8:13 PM] Post-residency PG 1: Specifically what type of work increased after 2002?
[1/29, 8:14 PM] MBBS UG Student 1: All the household activities listed above. That was the time she moved into her in-laws' place where she had to care for 15 people.
[1/29, 8:15 PM] Post-residency PG 1: 👆what was the daily household work here in comparison to what she did at her in laws?
[1/29, 8:16 PM] MBBS UG Student 1: Slightly less. But she still did rigorous work, compared to what she does now.
[1/29, 8:17 PM] MBBS UG Student 1: Due to the advent of washing machines, etc.
[1/29, 8:20 PM] MBBS UG Student 1: She went to an orthopedics surgeon who suggested she get operated for cervical disc bulge.
[1/29, 8:21 PM] Post-residency PG 1: Not needed. Even that MRI appeared unnecessary
[1/29, 8:21 PM] MBBS UG Student 1: The patient would like to avoid surgery, just like anyone else. What would you suggest, sir?
[1/29, 8:22 PM] Post-residency PG 1: Ask her to try short course NSAIDs after ensuring normal serum creatinine. What NSAIDs has she taken in the past that had brought down her pain?
[1/29, 8:40 PM] MBBS UG Student 1: These were the tablets given to her yesterday. She went to a Neurosurgeon. He advised her to take medication for 2 weeks and return for a follow-up.
[1/29, 8:41 PM] MBBS UG Student 1: The patient says that her pain has reduced after using the cervical collar and after taking the prescribed medication, since 1 day.
[1/29, 8:46 PM] Post-residency PG 1: Yes. It will reduce with these. 👍
Comments
Post a Comment