A 33 year old male with headache and stiffness of joints

Hello, I am Harshitha Shalini , a 5th semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.


A 33yr old male patient labour by occupation came to OPD with
 CHIEF COMPLAINTS:
Headache(on and off) since 1yr and stiffness of joints.

HOPI:
Patient of apparently asymptomatic 1yr back then he developed headache of unilateral side(Right) with full aching pain
-also had complaints of joint stiffness on sitting for a long time.
Negative history: no photophobia, no watering of eyes,no blurring of vision,no vomitings.
No restrictions of movement,no difficulty in standing,no fever,no abd pain,no SOB, no cough and cold 
 
PAST HISTORY:

Not known case of hypertension,DM,CAD,TB,epilepsy 

PERSONAL HISTORY:

married 
Appetite:normal 
Diet:mixed
Bowel: normal 
Micturition:normal 
No known allergies 
No addictions

FAMILY HISTORY: 

not significant 

GENERAL EXAMINATION:
No pallor,icterus,clubbing of fingers,cyanosis,lymadenopathy

Vitals:
Temperature:afebrile 
Pulse rate:90/min
Respiratory rate:16/min
BP:120/80mmhg
Spo2:98%
Systemic Examination 
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
vesicular breath sounds
Abdomen
Obese shaped abdomen 
 No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
INVESTIGATIONS:
ECG:
2D echo
Serum electrolytes
Serum creatinine
Blood urea
Random sugar
Provisional diagnosis:
U/L headache  ? Migraine 

Treatment:
Tab. Naproxen 250mg
Tab. Shelcal- CT

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