55 year old female with c/o headache

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT        

CHEIF COMPLAINTS:

PATIENT CAME WITH C/O HEADACHE SINCE 1 DAY DUE TO TRAUMA

HOPI:

PATIENT WAS APPARENTLY ASSYMPTOMATIC 5-6 YEARS BACK THEN SHE DEVELOPED GENERALISED WEAKNESS AND PALPITATIONS FOR WHICH SHE WENT TO HOSPITAL AND DIAGNOSED OF HAVING HIGH BLOOD PRESSURE AND STARTED MEDICATION.SHE WAS DOING FINE SINCE THEN TILL YESTERDAY MORNING WHILE DOING SOME HOUSEHOLD WORK SHE SLIPPED AND HIT HER HEAD TO A WALL IN OCCIPITAL REGION AND DEVELOPED SWELLING AND DRAGGING TYPE OF PAIN IN NECK.

N/H/O LOC, BLEEDING,RESTRICTION OF MOVEMENTS OF NECK, GIDDINESS, TINNITUS NO H/O SOB, COUGH, COLD, FEVER, SORE THROAT,ABDOMINAL PAIN, LOOSE STOOLS

H/O INTERMITTENT U/L HEADACHE ON RIGHTSIDE WHEN EXPOSED TO SUNLIGHT,

NO PHOTOPHOBIA

PHONOPHOBIA +

NO VOMITINGS 

BLURRNG OF VISION (FAR»NEAR)

WATERING OF EYES ABSENT

K/C/O HTN SINCE 5-6 YEARS ON T.AMLONG 5MG

PAST HISTORY

NO K/C/O DM,TB,EPILEPSY, CVA, CAD

FAMILY HISTORY :

NO SIGNIFICANT FAMILY HISTORY 

PERSONAL HISTORY :

MIXED DIET 

APPETITE NORMAL

REGULAR BOWEL AND BLADDER MOVEMENTS

SLEEP: INADEQUATE

ADDICTIONS: NO 

TREATMENT HISTORY:

PATIENT WAS ON TAB.AMLONG 5MG SINCE 5-6 YEARS 

UNDERWENT HYSTERECTOMY 20 YEARS BACK 

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COOPERATIVE,COHERENT AND ORIENTED WITH TIME , PLACE AND PERSON 
PALLOR +

KOILONYCHIA +
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA WAS NOTED

VITALS:

BP:120/90MMHG

PR:888PM

RR:17

TEMP:98.2F

GRBS:139MG/DL

SPO2:98% ON RA

SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD , NO MURMURS 

CNS:NO FOCAL NEUROLOGICAL DEFICIT

RS:

SHAPE OF CHEST IS ELLIPTICAL, B/L SYMMETRICAL.

TRACHEA IS CENTRAL. EXPANSION OF CHEST IS SYMMETRICAL

BILATERAL AIRWAY ENTRY - POSITIVE

NORMAL VESICULAR BREATH SOUNDS

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

? TENSION HEADACHE

TREATMENT:

T.NAPROXEN 250MG PO/BD

T.MVT PO/OD