50F with neck pain
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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