70 years old female with HEADACHE

70 Years old female with HEADACHE 

December 5th 2022
 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.

CHIEF COMPLAINTS 
70 years old female resident of miryalaguda  came to opd with chief complaints of headache since 6 months

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 6 months back, patient fell on the ground while doing some work due to obstacle in her way this is the incident that occurred 9 months before and 2 months of that incident she developed Headache which was insidious in onset and intermittent in nature and diffuse type with no aggrevating and relieving factors.
Headache is not associated with fever, seizures,vomitings, giddiness,loss of consciousness,weakness in upper limb and lower limb

Patient also had left and right Knee pain since 6 months.Left Knee pain is more compared to right side Knee pain. Pain is aggrevated on walking and relieved on rest and medication 

Generalised weakness since 1 month


PAST HISTORY 

No similar complaints in the past 

Not a known case of HYPERTENSION, DIABETES MELLITUS, ASTHMA, EPILEPSY, TB,Cardiovascular disease 

Underwent Bilateral cataract surgery 

History of injury to Head on right side due to falling 9 months back
  
No history of any other surgeries 

PERSONAL HISTORY 
 Diet is mixed 
Appetite is reduced
Sleep is disturbed (due to Headache)
Bladder movements are regular 
Constipation is present (passage of 1 stool per 3 days)
No Addictions 

FAMILY HISTORY 
 Not significant family history 

TREATMENT HISTORY 
 Used medication for Headache and Knee pain

GENERAL EXAMINATION 

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

No Pallor, cyanosis, clubbing,icterus generalised lymphadenopathy,Edema

Vitals:
Temperature is Afebrile
Blood pressure 110/70mmHg
Pulse rate 75 beats per min
Respiratory Rate 16 cycles per minute 


SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:
S1,S2 heard 
No murmurs 

RESPIRATORY SYSTEM:

BAE- present 
No wheeze
Trachea position -Central 
Breath sounds -vesicular

ABDOMINAL EXAMINATION 
 Abdomen is soft and non tender

CENTRAL NERVOUS SYSTEM 


CNS Examination

Higher mental functions:

Oriented to time,place,person

Memory :  Immediate,recent, remote intact

Speech: Normal

No delusions or hallucination

Cranial nerves: 

1- not tested

2- Pupillary reflex present

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing


Motor examination:

Tone -normal in both limbs 

Power-.                     Right    Left

             Upper limb   5/5       5/5

              Lower limb   5/5      5/5

Reflexes :

Biceps: Right++

               Left: ++

Triceps: Right++

               Left: ++

Supinator: Right++

               Left: ++

Knee: Right: ++

           Left: ++

Ankle: Right: ++

             Left: ++

         

Cerebellum examination:

Able to do finger nose test.

Able to do  dysdiadokinesia 

Gait: normal

  Robert sign is positive                                                                

LAB INVESTIGATIONS 
HAEMOGRAM 
LIVER FUNCTION TESTS

 SERUM ELECTROLYTES 


 BLOOD UREA

BLOOD SUGAR


ERYTHROCYTE SEDIMENTATION RATE


 SERUM CREATININE 


ECG


CHEST X RAY 


PROVISIONAL DIAGNOSIS 

HEADACHE UNDER EVALUATION 

TREATMENT 

TAB ULTRACET QID
TAB PAN 40Mg OD
Inj optineuron 1Amp / in 100ml



 

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