35 year old female C/O head ache and neck pain


Dec 29 2022
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan 

 
35 year old female presented with the c/o of headache, neck pain since two months, tingling sensation of left hand since two months and left shoulder pain since 2 months

HOPI
35 year old female presented with the c/o of headache, neck pain since two months, tingling sensation of left hand since two months and left shoulder pain since 2 months
- Patient was apparently asymptomatic 2 months ago after which she developed headache in occipital region which is stabbing type, not associated with nausea, vomitings, aura, photophobia, lacrimation.
H/O neck pain since 2 years which is dragging type not associated with rigidity, stiffness.
-She has history of head trauma 1 years ago after which she had LOC for 5 min, not associated with vomitings, ENT bleed 
H/O giddiness since 1 year which lasts for 2-3 minutes not associated with postural variation, tinnitus 
K/C/O HTN since the last two months (on regular medication, Tab Telma 40mg po od) 


EXAMINATION 
Pt is C/C/C
No pallor, Icterus,cyanosis,clubbing,lymphadenopathy,Generalised edema 
BP:140/100mm hg
PR:90bpm
RR:16/min
Temp : Afebrile 
CVS:S1S2 +,No murmurs 
RS :Bilateral air entry present 
       Normal vesicular breath sounds heard 
PA- soft, non tender 
CNS-
CNS:
Pupils- left- NSRL
             right-NSRL
Higher mental functions
- Conscious
- Oriented to time,place and person
- Memory - Intact
- Speech - no deficit

Cranial nerve examination 

          • 1 - olfactory sense - normal

          • 2- visual acuity present,direct reflex R L
                                     +. +                 
            Indirect reflex + +
          • 3,4,6 - no ptosis Or nystagmus

          • 5- corneal reflex present 

           • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

          • 8- Normal hearing

          • 9,10- position of uvula is central ,Gag reflex- present

          • 11- sternocleidomastoid contraction present

          • 12- no deviation of tongue
 Motor system 

Reflexes 
                          Right Left            
Biceps 2+ 2+      
Triceps 2+ 2+       
Supinator 2+ 2+
 Knee. 2+. 2+
Ankle. 2+ 2+
Plantars- flexion Flexion
Power. Lt. Rt
Upper limb -5/5. 5/5

Lower limb -5/5 5/5                                  
               

TONE. Lt. Rt
 Upper limbs N N                
 Lower limbs N N               

No Involuntary movements
 SENSORY SYSTEM

I – SPINOTHALAMIC R L
1. Crude touch N N 
2. Pain. N. N
3. Temperature. N. N
II – POSTERIOR COLUMN
1. Fine touch. N. N
2. Vibration. N. N
3. Position sense. N. N
4. Romberg’s sign -Negitive
III – CORTICAL
1. Two point 
    discrimination. N. N
2. Tactile localisation. N. N
3. Graphaesthesia. N. N
4. Stereognosis. N. N
 CEREBELLAR Tests
No Nystagmus
Finger Nose test - normal
Heel Knee test - normal
Dysdiadokokinesia - normal


Provisional diagnosis 
Neck pain under evaluation (?cervical spondylosis) 
K/C/O HTN since 2 months 


Treatment 
Tab HIFENAC MR po od 
Tab PAN 40mg po od bbf
Tab NUROKIND LC po od hs 
Monitor vitals and inform sos

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