60 yr old female with headache and neck pain

This is an online e log book to discuss our patient 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 centered online learning portfolio and your valuable inputs on the comment box is welcome.

Name : SANTOSH KUMAR .K ( Intern ) 

Roll Number : 62

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 plan. 
Chief COMPLAINTS 
C/O HEADACHE SINCE 2 MONTHS 
NECK PAIN SINCE 2 MONTHS 
TINGLING AND NUMBNESS OVER BODY SINCE 2 MONTHS 
HOPI 
PT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS  AGO THEN HER HUSBAND DIES WHILE WORKING IN FARM FOLLOWING WHICH SHE DEVELOPED HEADACHE  MOSTLY IN THE B/L TEMPORAL REGION 
ASSOCIATED WITH PHOTOPHOBIA ,PHONOPHOBIA
No history of  dizziness , vomiting ,or trauma 
Neck pain since 2 months  radiating to the bilateral shoulder and the upper limb ,pricking type of pain relieved with medication .neck pain not aggrevated by head movements .H/o involuntary movements of since 1 year.

Pain associated with morning  stiffness , which relieved by duration and by doing work
Tingling and numbness in the body more seen in head 
H/o bilateral knee pain took nsaid for knee pain relief . 

Past history 
H/o lt thigh fracture 10 years ago 
K/c/o htn from 8 yrs on medication Amlong 5 mg po od 
Not k/c/o DM TB, epilepsy asthma 

Personal history

DIET- mixed
Appetite: Normal
Bowel and bladder movements are regular
Sleep: disturbed decreased duration and increased latency
No addiction and allergies

General examination
Pt is  conscious , incoherent, cooperative
No pallor
      Icterus
      Cyanosis
       Clubing
       Lymphadenopathy
Vitals
         BP 120/70mmhg
         PR 79 BPM
         RR 20
         Spo2 95 
Systemic examination
       Respiratory examination
        BAE +ve and normal vesicular breath sound                 heard 
        No crepts heard 
      CVS examination
       S1S2 heard 
        No murmurs heard
        Abdomen examination
        Soft non tender
        No hepatomegaly and splenomegaly
CNS examination 
Higher mental functions  intact
CN examination.   Intact
Motor and sensory  system intact and normal 
Local examination 
Swelling of bilateral knee present
Swelling of inter phalyngeal  joint s seen 

Provional diagnosis
 
Neck  and shoulder pain  due to ?Rheumatoid arthritis 
Investigation 










Xray


2d Echo showed :
 No RWMA; No  MR;  Trivial ARand TR positive , No AS/MS; IAS Intact; EF 63%; Good  LV systolic function; diastolic dysfunction positive;
Mild LVH seen 

Ecg 

Treatment
1 T  ultracet half tablet Po/ Qid
2 T  CINOD T Po / OD 
3 T pan 40 mg Po / Od 
4 T Jointace P po /od 
5 Monitor vitals 4 th hrly.

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