Case Presentation:

Patient Details:

Name:

Age/gender: 40 Years Old man (male)

Profession: Receptionist of a company for last 15 years

Residence: Hawler-Brayati

………………………………………………………………………………………………….

Chief Complaint: Severe headache attacks for the last month

History of present illness: Maghdid ahmed is a patient presented with history of sever attacks of
headache for the month as he has started afternoon naps and disturbed his night sleeps, with a
history of intermittent low back pain as long as he remembers ,and after waking up for early
mornings he would experience an excruciating and burning pain above and behind his left eye, the
pain was severe that he could feel something pulsating on the side of his head, after the pain was
subsided after half an hour he could see his left eye turned red, swollen and teary, he explains that
the headache continues as he wakes up at 5 am, 3-4 times per week, he denies any increase in
symptoms.

-left side of the head and above and behind his left eye

-Sudden severe attacks 3-4 times per week every 30 minutes

-characteristically the pain was so severe, stabbing and constant, one sided

- According to the radiation he reports about his left eye

-the pain associated with tearing of the eye, redness of the eye with swelling ,discharge of his nose
in the nostrils, restlessness, sometimes facial sweating , even sometimes flushing of his face

- concerning timing he holds the pain is every 30 minute to one hour 3 to 4 days of a week , several
attacks in the same day after waking up mornings start till the end of the day

- The pain was aggravating by lying down also when he smokes, only relived by walking around in a
quite area also sometimes by hitting his head he reports that the pain was subsided

Past medical history of the patient: Diabetic and hypertensive

Having no previous history of surgeries except Hernia

Family History: Diabetic father and grandmother with cardiovascular disease

Social History: a smoker of one packs per day not alcoholic and married having 5 healthy children

-Takes drugs for his hypertension also his diabetes

GENERAL EXAMINATION

Vital signs:

Heart rate: 88

Blood pressure: 125/80 (Controlled with antihypertensive drugs)

Respiratory Rate: 14

*Having No fever NOW

Sensation: intact

Reflexes: intact

-NOW color of the nails is roughly pinkish no pallor no deviations of tongue and tongue is a little bit
whitish because of smoking

-RANGE OF MOTION

Cervical Flexion – With Normal Ranges

Cervical – With Normal ranges

Cervical Right/left Rotation – With normal Ranges

Cervical Right/Left Side Bend – With Normal Ranges

Manual Muscle Test:

Cervical extension and Flexion – 5/5

Cervical Rotation – 5/5

Shoulder Flexion – 5/5

Shoulder IR/ER – 5/5

Shoulder ABD-5/5
Elbow Flexion and Extenion-5/5

Scapular retraction-3/5

Palpitation:

No palpable tenderness along suboccipital, upper trapezius, or levator scapulae muscles.

Balance and vestibular assessment: