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
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