50F with pain in left lateral side of head and neck

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This is an a 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

A 50 year old female,masonry worker by occupation,resident of nalgonda came to OPD with C/o 
Pain in the left ,lateral side of head and neck since 3 months
HOPI
Patient was apparently asymptomatic 3 months back then she had pain in the left lateral side of had and neck which is insidious in onset, gradually progressive, unilateral, dragging type of pain, non radiating, aggravating while sleeping with no relieving factors. 
No numbness and tingling sensation
No burning sensation in the feet
H/o trauma  5 years back

Past History
No diabetes,hypertension, asthma, epilepsy, TB,CAD
H/o trauma 5 years back
Underwent hysterectomy 20 years ago

Personal History
Mixed diet
Appetite - normal
Regular bowel and bladder movements
Sleep - adequate
Addictions
Betel leaf consumption since 30 years
Occasional alcoholic
No known allergies

Family history
No significant family history 

GENERAL EXAMINATION 
Patient is conscious,coherent and cooperative
Moderately built and nourished
No signs of pallor,icterus,cyanosis,clubbing,pedal edema and lymphadenopathy 
VITALS
Temp - Afebrile
BP - 110/70mmHg
Pulse rate - 86bpm
Respiratory rate - 17 breaths/min

LOCAL EXAMINATION 
Inspection
No swelling in the left lateral side of head and neck
Palpation
Tenderness present
No local rise of temperature 

SYSTEMIC EXAMINATION 
CVS - S1,S2 heard,no murmurs
RS - BAE+, Normal vesicular breath sounds heard
CNS - No neurological deficits
Per abdomen - soft and non tender 

Treatment
Paracetamol 650mg TID


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