A 45 year old woman complaints of lower back pain and neck pain

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CHIEF COMPLAINTS:

A 45years old woman came to OPD with chief complaints of neck pain on and off since 6 years when she feels that she has high sugars and pain radiating towards shoulders causing headache.

She also complaints of Low back pain on and off since 2 to 3 years only when she is sitting for long hours.

HISTORY OF PRESENT ILLNESS

Patient is a k/c/o Type 2 diabetes mellitus diagnosed 6 years ago.

Patient had c/o polyuria 6 years back then got on routine investigation, she was diagnosed with type 2 dm

k/c/o HTN since 2 years but not on anyregular medication

HISTORY OF PAST ILLNESS

Not a k/c/o CAD, ASTHMA, EPILEPSY, CVA, TB, THYROID Disorders

PERSONAL HISTORY :

Married,

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

Patient has a habit of chewing tobacco occasionally since 2 to 3 months

FAMILY HISTORY: 

Not significant

GENERAL EXAMINATION:

No Pallor , icterus, cyanosis, clubbing,lymphadenopathy, edema

SYSTEMIC EXAMINATION:

CVS: S1,S2 heard, no murmurs heard 

Respiratory system: No dyspnoea and wheeze

Breath sounds vesicular

Abdomen: No abnormalities seen.

CNS: No abnormalities seen.

DIAGNOSIS:

Type 2 diabetes mellitus

TREATMENT:

Daily postural bp monitoring

Tab. Glimeperidine 2mg and metformin 1000mg PO/BD twice daily