27 year old male with throbbing central headache and diziness with history of head trauma

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE SHEET

Chief complaint: Headache and diziness since one year which was worse 10 days ago and lasted for 4 days. 

2 episodes of falling down in last month due to dizziness

History of presenting illness: Patient was apparently asymptomatic 1 year ago. Head Trauma 3 years ago following which CT scan was done and all appeared to be normal. 

Patient developed headache and diziness 1 year back with each episode lasting for 3 to 7 days. Pain is of throbbing type and is in the centre of the head radiating to the back of head near occiput. Pain is aggravated on lifting heavy weights and mildly releived on rest. Pain is associated with dragging pain in the left hypochondrium near the ribs. Patient complains of noise intolerance and sleep disturbances. 

Patient recollects worst headache episode in the may of last year which lasted for 3 to 4 days for which patient visited a local doctor and was prescribed propranolol which provides mild releif. 

History of past illness: Patient recollects worst headache episode in the may of last year which lasted for 3 to 4 days for which patient visited a local doctor and was prescribed propranolol which provides mild releif. 

History of MI in 2022.

No history of diabetes, tb, epilepsy, hypertension. 

Drug history: 

Propranolol for headache

Sucralfate syrup

Cobalife tablets

Personal history: 

Veg diet. Reduced due to bloating

Bowel and bladder movements otherwise normal, increased bowel movement since 10 days. 

Sleep inadequate and difficulty in falling asleep since 3 years. 

No addictions

No allergies

Family history:

 Father has low pulse

Uncle has kidney disease

General examination:

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Koilonychia: absent

Lymphadenopathy: absent

Edema: absent

Visceral fat: 

Vitals:

Temperature: afebrile

Respiratory rate: 16 per minute

Pulse : 74bpm

Blood pressure: 130/90mm of hg

CVS examination: S1, S2 heard, no murmurs

Respiratory system examination: No vesicular breath sounds

. 

CNS examination:

Higher functions: Intact

Speech: Normal, no slurring or delay

Gait: Normal

Cranial nerves: Intact

Laboratory investigations:

Blood sugar

Hemogram:

Urine analysis:

LFT

RFT

BLOOD UREA

Creatinine

HIV

HBC

HEPATITIS B

ECG

IMAGING:

Provisional Diagnosis: anxiety disorder? Referred to psychiatry

Treatment:

Day1