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.


CONSENT AND DE-IDENTIFICATION : 

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.


46 year old female who is resident of Nalgonda came to the GM OPD with the chief complaints of bilateral headache associated with neck pain since 20 days

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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