28 yr old male patient with pain in the backside of neck along with headache since 8 months

28M with pain in the back of neck and headache

25th September 2023

Case of a 28yr old patient with pain at the back of neck along with headache 

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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 

A 28 yr old came to the old with chief complaints of neck pain(backside)

along with headache and pain in the eyes(dragging type)since 8 months

HISTORY OF PRESENT ILLNESS 

The patient was apparently asymptomatic 8 months ago then developed pain in the backside of neck along which was progressive in nature  with headache and dragging type of pain in the eye

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.

He had a nose surgery 5 year's ago.

FAMILY HISTORY 

No significant family history

PERSONAL HISTORY

Used drink alcohol n stopped 8 months ago

GENERAL EXAMINATION

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

VITALS

PR: 70bpm

BP: 120/80mm hg

RR: 16 bpm

TEMPERATURE: 98F