43 y/o woman with c/o headache since 2 yrs

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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.

5 November 2023 

Case - 

DOA -  4/11/23 

Chief complaints -

Patient came to GM OPD with chief complaints of  

-headache since 2 yrs 

-low back ache since 6 months 

-abdominal bloating since 6 months 

History of presenting illness - 

Patient was apparently alright 2 yrs back then she developed headache which is severe, diffuse type and increased on exposure to light and excessive sounds. It is associated with aura. Patient also has sensation of heat dissipating from her face during these episodes of headache. It is more during night causing disturbed sleep. Headache is increased in intensity since 3 months, it is continuous and is only temporarily relieved on taking paracetamol. Headache is also associated with giddiness. 

No h/o nausea, vomiting, blurring of vision, ear pain, tinnitus

No h/o fever, cold, cough

No h/o sob, palpitations, chest pain

C/o low back ache radiating to legs since 6 months 

C/o abdominal bloating and tightness since 6 months 

H/o constipation present since 1 yr 

H/o flatulence present 

C/o dryness of mouth and lips since 1yr 

C/o pain and tingling sensation in both hands causing decreased hand movement 

Past history -

No h/o similar complaints in past 

N/k/c/o DM, HTN, TB, asthma, epilepsy, CVA, CAD, thyroid disorder 

Patient noticed a swelling on her right upper limb one day which slowly increased in size. It was found to be a tumor and excised 7 yrs back.

 

Family history - 

No significant family history 

Personal history - 

She is a housewife who does her daily chores. She is unable to do her household work effectively since the time she has headache and takes more rest. 

Appetite - decreased 

Diet - mixed 

Sleep - decreased 

Bowel - constipation + 

Micturition - normal (goes only once during day) 

Addictions - betel leaf consumption , stopped since 10 yrs 

No known allergies 

General physical examination - 

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

She is well-built and nourished 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 

Dryness of mouth and lips + 

Vitals on admission - 

Temp - Afebrile 

BP - 120/80 mm hg 

PR - 78bpm 

RR- 18cpm 

GRBS - 134mg/dl 

Systemic examination - 

CVS:  S1, S2 heard , no murmurs 

CNS:  NAD 

RESP SYS:  B/L air entry + , trachea central , NVBS heard 

P/A : obese, soft, non tender, no organomegaly 

Ophthalmology referral done I/v/o papilledema changes - 

Impression - no papilledema changes noted 

Advice - continue wearing same spectacles 

Use eye drops LUBREN 5 times daily for 5 days 

Gastroenterology referral done I/v/o abdominal distension and constipation 

Impression - dysphasia and dysmotility 

Advice - Tab PRUEASE 1mg PO OD (9pm) 

               Cap VELOZ-D PO OD BBF 

               Consumption of green leafy vegetables 

               Avoid spicy and fatty foods 

Neurology referral done I/v/o headache and giddiness 

Impression - ?vestibular migraine 

Advice - Tab ELIWEL 10 PO OD 

               Tab XENADOM 500 PO SOS 

               Vestibular relaxation and neck muscle exercises 

               Avoid migrainous triggers 

Psychiatry referral done I/v/o somatization disorders 

Patient was psychoeducated and reassurance given. 

Relaxation and diversion techniques were explained 

Investigations adviced : 

 

Provisional diagnosis - 

? Vestibular migraine  ?cervical spondylosis ?dysphasia and dysmotility 

Plan of treatment  - 

Tab PARACETAMOL 650 mg PO QID 6th hourly 

Tab AMITRIPTYLLINE 25 mg PO HS 

Tab AVOMINE PO OD 

Tab ELIWEL 10 PO OD 

Tab XENADOM 500 PO SOS 

Tab PRUEASE 1mg PO OD (9pm) 

Cap VELOZ-D PO OD BBF

Tab MVT PO OD 

Tab SHELCAL PO OD 

Physiotherapy exercises for low back ache 

Vestibular relaxation and neck muscle exercises 

Avoid migrainous triggers