50F with neck pain

 


Hi, this is Shreshta Reddy Adla, a medical student currently studying in KIMS Narketpally. This page is a compilation of cases taken up during my medical school years, with an intent to correlate theoretical concepts of medicine to practical aspects of it. These E-logs have been created after taking consent from the patient and the patient's advocate. So welcome, and I encourage you to immerse yourselves into these interesting cases.

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 


This is the case of a 50 year old female from nalgonda who came to the opd with 

CHIEF COMPLAINTS 

Of pain in the left lateral side of the head and neck since 3 months

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 3 months back then she had pain in the left lateral side of the head and neck which is insidious in onset, gradually progressive, unilateral, dragging type,non radiating, aggravating while sleeping with no relieving factors

H/o trauma 5 years back

No numbness and tingling sensation

No burning sensation in the feet


PAST HISTORY 

Underwent Hysterectomy 20 years back

No diabetes 

No hypertension

No TB,Epilepsy,CAD,Asthma


GENERAL EXAMINATION 

Patient is c/c/c and is examined in a well ventilated and lit room with consent 

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


VITALS

Temp- afebrile

PR - 86bpm

BP- 110/70mmHg

RR- 17 breaths/min


LOCAL EXAMINATION 

Inspection

No swelling in the left lateral side of head and neck

Palpation

Tenderness present

No local rise of temperature


SYSTEMIC EXAMINATION 

CVS- S1,S2 heard,no murmurs

RS - normal vesicular breath sounds heard

CNS - No neurological deficit

Per abdomen - soft and non tender No swelling in the left lateral side of neck







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