18 year old female with 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 patient's clinical problems with collective current best evidence based inputs.
This Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .
December 5 2022
CHIEF COMPLAINTS
18 year old female resident of nampally studying intermideate second year came with complaints of headache since 1 year
HOPI
Patient was apparently asymptomatic 5 years back then she developed headache which is intermittent relived on medication or rest.
Then since last year there is history of frequent episodes of headache in bilateral temporal regionthen she went to the hospital in nampally , then they checked vision and prescribed spectacles.But she has no relief even after wearing spectacles.
Since last 6 months pain is more severe in bilateral temporal region and parietal region throbbing type, pain presenting throughout the day and increasing at night, each episode lasting for 2 to 3 days. Aggravating on intake of cold foods, fruits and intake of more amount of water,intake of curd, listening to loud sounds. Relived temporarily on rest.
Pain is not associated with fever , vomiting , nausea , aura , vision distrubance , diplopia, auditory problems , lacrimation, aural fullness,ptosis,nasal congestion.
One month back she went to another hospital , where they prescribed medication
ESCITALOPRAM 5mg
SERTVALINE 25 mg for month. After using medication she didn't feel any improvement.
Then 20 days back on November 11 2022 she came KIMS narketpally then prescribed medication ( calcium, pantop and multivitamin tablets) for 10 days.
Again 10 days back on 29 November 2022 she again came to the hospital complaining no improvement then prescribed medication (tab.Ibuprofen and Amitryptiline) for 10 days.
Again she came today on Dec 5 2022 that she did not relived even after medication. Then She was admitted in the hospital.
PAST HISTORY
No history of Diabetes mellitus, hypertension,asthma, tuberculosis, thyroid abnormalities.
No history of any type of trauma to the head.
FAMILY HISTORY
Mother has similar complaints of throbbing type of headache in bilateral temporal region when consuming cold foods lasting for 2 to 3 days , relived on medication and rest.
PERSONAL HISTORY
On normal days ( without headache)
She wakes up between 6 to 7 am , then she completes her regular activities.
8 am - breakfast ( Rice + any curry)
9 am she goes to collage in same town by walking.
1 pm - lunch ( same thing which she ate in the morning) .
4pm - she comes back to home by walk.
She does some household chores upto 5 to 5:30. And she takes rest for some time.
Then she starts doing her college work ,
Dinner at 8 pm and sleeps by 9 pm
On the days of headache she wakes up lately and she takes food and again she takes rest.she won't do any activities during those days.
Diet : mixed, Appetite - normal
Distrubance in sleep due to pain.
Bowel and bladder movements were regular.
No addiction and allergies .
GENERAL EXAMINATION
Patient is concious, coherent and coperative well oriented with time and place.
No Pallor
No icterus
No edema.
VITALS
Temprature - afebrile
Pulse rate - 73 bpm
BP -120/80 mmHg
RR- 18 cycles / min
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1, S2 heard, no murmers
RESPIRATORY SYSTEM
Bilateral airway intact , Normal vesicular breath sounds heard.
PER ABDOMEN
Soft , non tender , no organomegaly.
CNS
No neurological deficits.
INVESTIGATIONS
On Dec 5
TREATMENT
On Dec 05
Tab.Naproxen 250 mg orally for 5 days. Tid
Tab.multivatamin OD for 15 days.
PROVISIONAL DIAGNOSIS
Headache under evaluation.
Comments
Post a Comment