49 year old with headache

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.

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.
 


This is a case of a 49 year old female resident of Devarakonda

CHIEF COMPLAINTS

Headache since 1 year.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1 year back when she developed headache that is insidious in onset, gradual in progression without any aggrevating or relieving factors. The episodes of headache have aggrevated over the past 3 days, around 4 episodes have occurred. Each episode last around 1 hour and is relieved on medication. Headache is diffuse, throbbing type and is affecting the daily life of the patient. It is associated with photophobia, phonophobia and nausea.
It is not associated with fever, vomitings, lacrimation.
She was diagnosed with a deviated nasal septum towards the right side with associated left maxillary sinusitis 2 months back.

Patient also has bilateral loin pain since the past 15 days that is insidious in onset, non-progressive. It is associated with decreased urine output for the past 15 days. She is also experiencing burning micturition.

PAST HISTORY

No similar complaints in the past.

She is a known case of hypertension since 1 year on Tab. Amlodipine 5mg.

No known history of diabetes mellitus, tuberculosis, epilepsy, asthma, thyroid disease.

PERSONAL HISTORY

She has a mixed diet, normal appetite, regular bowel movements, no addictions.
She has experienced disturbed sleep for the past 5 months, regular episodes of early awakening have happened over this period.

DAILY ROUTINE

She wakes up at 4'oclock in the morning and does her daily routine activities like cleaning the house, cooking. She then goes to cotton fields at 9'oclock in the morning and works there till evening.
She has her lunch in the fields itself at around 1'oclock in the afternoon and comes back to home at 5'o clock. Then she prepares dinner for her family and has her dinner around 9'o clock.

FAMILY HISTORY

No significant history in the family.

SURGICAL HISTORY
Hysterectomy 16 years ago


GENERAL EXAMINATION

Patient is conscious, coherent and cooperative , well oriented with time, place and person

She is moderately built and nourished.

She has no pallor.


Icterus - Bulbar conjunctiva is clear




No cyanosis, clubbing, generalized lymphadenopathy or pedal edema.

VITALS - 

Temperature - 37 degrees Celsius
Pulse rate - 82 bpm
Respiratory rate - 16 cpm
Blood pressure - 150/100 mm hg





CNS EXAMINATION

 1) HIGHER MENTAL FUNCTIONS - 

 The patient is conscious, appears comfortable, language and behaviour appears normal.

- Orientation to time place and person normal. Mood and emotional status appears normal.

- Memory: immediate, recent and remote memory tested- normal.

- Mini mental status examination score- 
                Orientation-5/5
                Registration-3/3
                Attention and calculation- 5/5
                Language -9/9
                Recall -3/3
                Total score- 30/30

- No illusions or hallucinations

- Speech - normal verbal output, fluency, repetition, naming, reading, writing.

- Appearance- no tics, tremors, myoclonus, involuntary or voluntary movements


2)CRANIAL NERVES- right. Left

1.OLFACTORY NERVE:
Sense of smell - normal. Normal

2.OPTIC NERVE:
Visual acuity - normal Normal
Field of vision- normal Normal
colour vision. Normal. Normal
fundus. Normal. Normal

3.OCULOMOTOR NERVE

4.TROCHLEAR NERVE

6.ABDUCENS NERVE : 
-extra ocular movements:Normal

-pupils: Normal size and reacting to light on both sides
-direct and consensual light reflexes normal in both eyes
No Nystagmus
no ptosis

5.TRIGEMINAL NERVE:
 Sensory : sensations over face normal on both sides
 Motor - massater,temporarils, pterygoids normal

7. FACIAL NERVE:
 Motor : Nasolabial fold,Orbicularis oculi, orbicularis Oris ,occipital frontalis, 
buccinator -normal on both sides
 Sensory : taste over anterior 2/3rd of tongue normal on both sides

8. VESTIBULOCOCHLEAR NERVE:
Rinnes test normal on both sides
. Webers test normal on both sides

9.GLOSSOPHARYNGEAL NERVE
10.VAGUS NERVE:
 Uvula , palatal arch movements normal.
Gag reflex. - normal
Palatal reflex - normal

11. SPINAL ACCESSORY NERVE:
Tarpezium and sternocleidomastoid -normal

12. HYPOGLOSSAL NERVE:
No wasting and fasciculations of tongue
Tongue protrusion to midline.


3)MOTOR SYSTEM:
Bulk:normal on both upper and lower limbs
Tone:normal on both upper and lower limbs
Power:5/5 on both upper and lower limbs

4)REFLEXES:
Ankle

Triceps 
Knee 
Biceps
Supinator

BABINSKI'S SIGN



INVESTIGATIONS



1) ECG - 



2) CHEST XRAY - 


3) INVESTIGATIONS:
HEMOGRAM:
Hb:13.0
RBC:4.15
TLC:5,800
NEUTROPHILS:59
LYMPHOCYTES:35
EOSINOPHILS:01
MONOCYTES:05
BASOPHILS:00
PCV:37.1
MCV:89.4
MCHC:35.0
RDW:11.6
PLT:3.01
URINE EXAMINATION
COLOUR:PALE YELLOW
APPEARANCE:CLEAR
SPECIFIC GRAVITY:1.010
ELECTROLYTES
Na+=137
K+=3.8
Cl-=102
Ca+=1.00

PROVISIONAL DIAGNOSIS

Headache under evaluation 


My differential diagnosis would be : 

Tension type headache
Migraine
Sinus headache

TREATMENT

Tab. Naproxen+Domperidone 250mg PO/BD
Tab. Amlodipine 5mg
BP monitoring and charting every 4th hourly.



1) Neurobiology of headache
https://pubmed.ncbi.nlm.nih.gov/15914251/

2) Diagnostic criteria of migraine
https://share.marrow.com/P2L96vzHwvb

3) Migraine and the risk of incident hypertension in women
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026578/









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