60 yr old female with headache and neck pain
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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
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.