55yr Female patient with headache and neck pain

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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 .

A 55 year old female patient came to the general medicine opd with chief complaints of headache and neck pain since the last 15 days 

HOPI: 

Patient was apparently asymptomatic 15 days ago then she developed a  headache which was diffuse and of dull aching type  associated with photophobia , no a/w any phonophobia

H /o neck pain since 15 days diffuse and  aggravated on extension of the neck but not associated with any joint stiffness or restriction of movements

Patient also has a h/o tingling sensation in both the upper limbs since the last 15 days not a/w with any swelling or redness

Patient also complains of chest tightness,not a/w with any shortness of breath or cough

Patient had a history of fever 15 days ago which was relieved on medication 

Not a known case of DM/HTN/ TUBERCULOSIS/ASTHMA/

PERSONAL HISTORY:

Appetite: decreased

Diet:mixed

Sleep: adequate

Bowel and bladder are regular

Patient denies of any addictions

FAMILY HISTORY:

no history of similar complaints within the family

General examination

Patient is conscious, coherent and cooperative

Well built and we'll nourished 

Pallor: absent 

Icterus:absent

Clubbing: absent

Cyanosis: absent

Lymphadenopathy: absent

Edema: absent

 

VITALS:

BP  120/80

Heart rate 78 bpm

Resp Rate 17/min

Sp02 98%

GRBS 

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM:

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry, no added sounds 

CVS EXAMINATION:

I: No precordial buldge. Apical impulse

visible, Venous prominence

P: Apical impulse, No palpebral pulsation.

thrill

A: S1 S2, No murmur

ABDOMINAL EXAMINATION:

Abdomen is soft and non tender

No organomegaly

No shifting dullness

No fluid thrill

Bowel sounds heard

PROVISIONAL DIAGNOSIS 

Cervical spondylosis

Bilateral osteoarthritis of the knees

Headache under evaluation 

INVESTIGATIONS

X-RAY B/L KNEE