A 75yr old pt. c/o headache

LEARNER REPORT
"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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comments box.


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 A DIAGNOSIS AND TREATMENT PLAN.


A 75 YR OLD FARMER BY OCCUPATION
 C/O HEADACHE SINCE ONE MONTH.
IT IS NON RADIATING AND NOT ASSOCIATED WITH NAUSEA OR VOMITING .
NO AGGRAVATING FACTORS BUT IT IS RELIEVED ON MEDICATION 
NO C/O SHORTNESS OF BREATH , DYSPNOEA , 
NO C/ O BURNING MICTURITION , PEDAL EDEMA 
H/O PARALYSIS 5 YRS BACK 
THERE NO SIMILAR COMPLAINS IN THE PAST 

PAST HISTORY
HE IS K/C/O DM SINCE 5 YRS AND HTN SINCE 5 YRS AND IS ON REGULAR MEDICATION 

PERSONAL HISTORY 
DIET - MIXED 
APPETITE - NORMAL
BOWEL AND BLADDER MOVEMENTS- NORMAL
ADDICTION - TODDY / BEER / WHISKEY SINCE 25 YRS AND DISCONTINUED SINCE 5 YRS 
SMOKING 1 PACK / DAY 

FAMILY HISTORY - NO SIGNIFICANT FAMILY HISTORY 
DRUG HISTORY - HE IS ON REGULAR MEDICATION FOR DIABETIS AND HYPERTENSION SINE 5 YRS

GENERAL EXAMINATION : PATIENT IS CONSCIOUS ,COHERRENT, CO OPERATIVE AND WELL ORIENTED TO HIS SURROUNDINGS.
HE IS MODERATELY BUILT AND NOURISHED.
NO PALLOR ,NO CYANOSIS, NO ICTERUS, NO LYMPHADENOPATHY. 

VITALS:. TEMPERATURE: AFEBRILE. 
PULSE RATE: 98 BEATS / MIN.
 RESPIRATORY RATE: 19 CYCLES / MIN.
 BP: 110/70 , 
SPO2: 99 
GRBS - 112 MG/DL

SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD


PROVISIONAL DIAGNOSIS
MIGRAINE

TREATMENT
1) TAB.NAPROXONE 250 MG PO / BD
2) TAB. PAN 40MG PO /OD
3) TAB . VERTIN 16 MG PO/BD







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