46 Y F with headache associated with neck pain 20 days
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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.
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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Patient was apparently asymptomatic 20 days ago then she had bilateral headache lasting for 30 min insidious in onset gradually progressive which is aggravated during the stressful condition relieved by using spectacles.
Tenderness present over cervical spine region
H/O chest pain which is draining type.
H/o of belching since 20 days.
No h/o burning sensation over the chest .
No h/o dysphagia,odynophagia, weight loss, vomiting,cough,
No h/o retroorbital pain, photophobia, phonophobia,photopsia.
Past history:
7 years ago she had surgery to left femur
N/K/C/o diabetes mellitus type 2, hypertension, asthma, TB, CVA, CAD, Epilepsy.
Personal history:
Appetite: decreased
Sleep: adequate
Bowels: regular
Micturition: burning sensation when she uses medication for pain relief in the leg.
7 years ago she worked as farmer after the surgery to the left femur she is not able to work due to pain so she stays in home.
General physical examination:
PR:76bpm
BP:110/70 mm hg
RR:18 cpm
Pallor: present
Icterus: absent
Cyanosis : absent
clubbing: absent
lymphadenopathy: absent
Edema : absent
Systemic examination:
Systemic examination:
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
- no dyspnea
- no wheeze
- tracheal position is central
- breath sounds : vesicular
- no adventitious sounds heard
Abdomen
- shape : distended
- no scars, striae or engorged veins
- bowel sounds heard
- no bruits, rubs
- no shifting dullness
- no fluid thrill
- no palpable mass
- hernia orifices : normal
- liver: palpable
- spleen : not palpable
CNS
- conscious
- normal speech
- cranial nerves -intact
-sensory systems
Touch present
Pain
Superficial present
Deep present
Vibration present
Sense of position present
Provisional diagnosis:
Tension headache
?Acid peptic disease
Treatment:
Tab Amytryptylline 10 mg po/hs 15 days
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