A 49 year old female with headache

December 5th 2022

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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.

A 49 year old female farmer by occupation and hailing from devarakonda

CHIEF COMPLAINTS:

Headache since 1year

Decreased urine output since 20days

Bilateral lower back pain since 15days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 year back then she developed headache which is insidious in onset and gradually progressive in nature and it aggrevates on bending forward and relieved temporarily on medication. The episodes of headache have aggrevated over the past 3 days, around 4 episodes/day and each episode lasting for 1-2hrs 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 from past 15 days which is insidious in onset, non-progressive. It is associated with decreased urine output for the past 15 days. She is also experiencing burning micturition.

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.

PAST HISTORY:

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

No similar complaints in the past

No history of DM,CAD,CVD,TB, Asthma and epilepsy

FAMILY HISTORY:

No significant family history

PERSONAL HISTORY:

Diet:mixed

Appetite:normal

Sleep: adequate

Bowel movements were regular but there is decreased urine output and burning micturition is present.

No addictions

No allergies

DRUG HISTORY:

She is a known case of hypertension and on TAB. AMLONG 5mg

SURGICAL HISTORY:

She underwent hysterectomy 15yrs back.

GENERAL EXAMINATION:

I had taken prior informed consent of the patient and examined in a well lit room

Patient is conscious ,coherent and cooperative moderately built and moderately nourished

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema-Absent

●She is having Deviated nasal septum towards right side.

VITALS:

TEMPERATURE: AFEBRILE

BLOOD PRESSURE:150/100mmHg

PULSE RATE:83bpm

RESPIRATORY RATE:14cpm

SYSTEMIC EXAMINATION:

•CARDIOVASCULAR SYSTEM:S1 S2 HEARD AND NO MURMURS

•RESPIRATORY SYSTEM:BAE+ NVBS HEARD

•PER ABDOMEN EXAMINATION: Right loin tenderness present.

•CENTRAL NERVOUS SYSTEM 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

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

                 

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:

•Bicpes:

•Triceps:

•supinator:

•Knee:

•Ankle:

•BABINSKI'S SIGN

VI – GAIT-Normal

6)AUTONOMIC NERVOUS SYSTEM

Postural Hypotension-absent

Resting tachycardia-absent

Abnormal sweating-absent

7)SIGNS OF MENINGEAL IRRITATION

Neck stiffness-absent

Kernigs sign-negative

Brudzinskis sign-negative

8) EXAMINATION OF SPINE AND CRANIUM

SPINE  bony deformities, bruit, tenderness-absent

CRANIUM  bony abnormalities, bruit-absent

10)CAROTID PULSE-normal

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

-ECG:

CHEST X-RAY:

PROVISIONAL DIAGNOSIS:

 Headache under evaluation.(MIGRAINE?)

TREATMENT:

1)TAB.NAXDOM 250mg/PO/BD

2)BP monitoring and charting every 4th hourly.

DISCUSSION.

My probable diagnosis could be migraine because of this following criteria