43 y/o woman with c/o headache since 2 yrs

Note - This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment.

5 November 2023 
Case - 

DOA -  4/11/23 

Chief complaints -
Patient came to GM OPD with chief complaints of  
-headache since 2 yrs 
-low back ache since 6 months 
-abdominal bloating since 6 months 

History of presenting illness - 
Patient was apparently alright 2 yrs back then she developed headache which is severe, diffuse type and increased on exposure to light and excessive sounds. It is associated with aura. Patient also has sensation of heat dissipating from her face during these episodes of headache. It is more during night causing disturbed sleep. Headache is increased in intensity since 3 months, it is continuous and is only temporarily relieved on taking paracetamol. Headache is also associated with giddiness. 
No h/o nausea, vomiting, blurring of vision, ear pain, tinnitus
No h/o fever, cold, cough
No h/o sob, palpitations, chest pain
C/o low back ache radiating to legs since 6 months 
C/o abdominal bloating and tightness since 6 months 
H/o constipation present since 1 yr 
H/o flatulence present 
C/o dryness of mouth and lips since 1yr 
C/o pain and tingling sensation in both hands causing decreased hand movement 

Past history -
No h/o similar complaints in past 
N/k/c/o DM, HTN, TB, asthma, epilepsy, CVA, CAD, thyroid disorder 
Patient noticed a swelling on her right upper limb one day which slowly increased in size. It was found to be a tumor and excised 7 yrs back.


 

Family history - 
No significant family history 

Personal history - 
She is a housewife who does her daily chores. She is unable to do her household work effectively since the time she has headache and takes more rest. 
Appetite - decreased 
Diet - mixed 
Sleep - decreased 
Bowel - constipation + 
Micturition - normal (goes only once during day) 
Addictions - betel leaf consumption , stopped since 10 yrs 
No known allergies 

General physical examination - 
Patient is conscious, coherent and cooperative and well oriented to time, place and person 
She is well-built and nourished 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 
Dryness of mouth and lips + 







Vitals on admission - 
Temp - Afebrile 
BP - 120/80 mm hg 
PR - 78bpm 
RR- 18cpm 
GRBS - 134mg/dl 

Systemic examination - 
CVS:  S1, S2 heard , no murmurs 
CNS:  NAD 
RESP SYS:  B/L air entry + , trachea central , NVBS heard 
P/A : obese, soft, non tender, no organomegaly 
 
Investigations adviced : 
Fasting serum lipid profile 

Provisional diagnosis - 
?Migraine ?cervical spondylosis 

Treatment given - 
Tab ULTRACET 1/2 tab PO BD 
Tab MVT PO OD 
Tab SHELCAL PO OD 

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