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CHIEF COMPLAINTS:
18yr old female student resident of nampally came with chief complaints of headache since 1 yr.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 years back then she developed headache which was intermittent relived on medication or rest.
Since last year there is history of frequent episodes of headache in bilateral temporal region for which she went to the hospital in nampally,checked her vision and prescribed spectacles.But she has no relief from pain even after wearing spectacles.
Since last 6 months pain is more severe in bilateral temporal region and parietal region throbbing type, pain presenting throughout the day and increasing at night, each episode lasting for 2 to 3 days. Aggravating on intake of cold foods, fruits and intake of more amount of water,intake of curd, listening to loud sounds. Relived temporarily on rest.
Pain is not associated with fever , vomiting , nausea , aura , vision distrubance , diplopia, auditory problems , lacrimation, aural fullness,ptosis,nasal congestion.
Two months back she went to another hospital , where they prescribed medication
ESCITALOPRAM 5mg
SERTVALINE 25 mg for month. There is no improvement in pain.
She visited our hospital twice in last there is no relieve of her headache.
Again she came 2days back and was admitted in the hospital.
PAST HISTORY:
No history of Diabetes mellitus, hypertension,asthma, tuberculosis, thyroid abnormalities.
No history of any type of trauma to the head.
FAMILY HISTORY:
Mother has similar complaints of throbbing type of headache in bilateral temporal region when consuming cold foods lasting for 2 to 3 days , relived on medication and rest.
PERSONAL HISTORY:
Diet- mixed
Appetite - normal
Sleep- Adequate
Bowel and bladder movements- regular
No addictions
GENERAL EXAMINATION
Patient is concious, coherent and coperative well oriented with time and place.
No Pallor,cyanosis, clubbing lymphadenopathy and edema
VITALS:
Temprature - afebrile
Pulse rate - 73 bpm regular rhythm, normal volume and no radiofemoral delay.
BP -120/80 mmHg right arm in supine position.
RR- 18 cycles / min.
SYSEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
S1, S2 heard, no murmers
RESPIRATORY SYSTEM:
Bilateral airway intact , Normal vesicular breath sounds heard.
PER ABDOMEN:
Soft , non tender , no organomegaly.
CNS:
No neurological deficits.
INVESTIGATIONS :
Provisional diagnosis:
Headache under evaluation.
Treatment:
Tab naproxen 250mg PO/TID
Tab multivitamin PO/OD
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