A 60 years old female with headache and neck pain

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

Chief complaint:  patient complains of Headache since 2 years ,
Neck pain since 1 year
Tingling and numbness all over body and head
HOPI : patient was apparently asymptomatic 2 years back then she had headache since 2 years on temporal region ( episodic) and pain on back of neck since 1 year 
History of past illness:- patient is a known case of hypertension since 9 years and type 2 diabetes since 7 years. 
Personal history: 
Diet: Mixed
Sleep : Adequate
Bowel and bladder movement: Regular
No addictions 
Family history: No member in family have similar complaints 
General examination: 
I have taken consent of patient. 
Patient is cooperative,coherent, well oriented to place , time, person.
Temperature: Afebrile. 
Pulse rate : 84/ min
Blood pressure:130/90mm Hg
RR:16/min
SpO2 : 97%
No pallor, cyanosis, clubbing, lymphadenopathy 
Systemic examination
Cvs:
No thrill felt
Cardiac sounds -S1 S2 +
Respiratory system
Trachea: positioned central 
Dyspnoea: No
Wheeze: No
Abdomen: 
Shape : scaphoid
Tenderness: Non tender
No palpable masses
No bruit
Liver : Non palpable
Spleen: Non palpable
Bowel sounds - Heard
CNS
Conscious
Speech - Normal 
Neck stiffness: No
Provisional diagnosis: cervical spondylosis. 
Investigations
Treatment
Tab ULTRACET
Tab pan 40 mg
Tab pregabalin
Tab Metformin
Tab Zoryl

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