38yr old female with pain in neck and headache

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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. 

CHIEF COMPLAINTS 

The patient came to the opd with pain in the neck and headache since 6 months

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 6 months ago then he developed lower backache on right side since 6 months 

Insidious in onset and gradually progressive in nature, dragging type of pain, intermittent in nature, aggravated while eating food and during night and relieved on rest and medication .

No C/O chest pain, orthopnea, PMD,decreased urine output, pedal edema or facial puffiness. 

PAST HISTORY 

Not a known case of hypertension, DM, CVA,CAD,TB, asthma.

Had a c section 14years agi and hysterectomy 13 yrs ago

FAMILY HISTORY 

No significant family history

PERSONAL HISTORY

Loss of appetite 

Diet mixed

Bowel movements regular

No burning micturition 

GENERAL EXAMINATION

No signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.

VITALS

PR: 78bpm

BP: 130/70mm hg

RR: 15bpm

TEMPERATURE: 98.4F

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

S1 S2 heard

no murmurs

RESPIRATORY SYSTEM: 

No added sounds