A 44-year-old female patient presented with severe headache, vomiting, neck pain radiating to the shoulder, giddiness, insomnia, blurred vision, frequent urination, burning urination, and lower back ache. Examinations and investigations revealed elevated ESR, bilateral sclerosing mastoiditis, septated maxillary sinuses, patent osteomeatal unit, and deviated nasal septum to the right. She was diagnosed with cervical spondylosis, sinus headache, migraine, and follicular tonsillitis. Her treatment plan included analgesics, antibiotics, corticosteroids, antidepressants, anxiolytics, antiemetics, and PPI. Tonsillectomy was also

1. Case study on
By,
G.MAHESH
Pharm.D VI yr
25-12-2013

2. Name:Mrs.x
Age:44yrs Wt: 76kg
Doa:21/12/13
c/o:
Severe headache left side since 1 wk
Vomiting 3 episodes since morning
Neck pain radiating to shoulder
Giddiness,insomnia,blurred vision,freguent
Urination, burning micturition,lower back ache

3. Past medical history:
Recently detected HTN on T.AMLONG 5mg 1-0-0
o/e:
Conscious,oriented,afebrile
BP-140/80 mm Hg CVS-s1s2+
PR-80 beats/min RS-NVBS
RR-20/min CNS-NAD
P/A-soft

4. INVESTIGATIONS:
CBC
Hb-10.1gm%
PCV-31.4%
RBC-4.14millioncells/cumm
WBC-9900cells/cumm
ESR-32/hr
MCV-75.8
MCH-24.4
MCHC-32.2
PC-4 lacs

5. RBS-74gm
Urea-32
Sr.cr-1
Na-144mmol/l
K-3.2mmol/l
Cl-102mmol/l
HCO3-22mmol/l
Total cholestrol-151
Triglycerides-75
HDL-42
LDL-94
VLDL-15
CHOL/HDL-3.6

6. CT scan of paranasal sinuses
IMP:
B/L sclerosing mastoiditis
Septated maxillary sinuses
Patent osteomeatal unit
Deviated nasal septum to right

8. DIAGNOSIS:
Cervical spondylosis, cervical
radiculopathy,SHT,migrain,

9. TREATMENTS
Brand Generic
Dose
Freq duration
19 20 21 22
Inj.monocef ceftriaxone 1gm bd s
t.Amlong amlodipine 5mg 0d s
t.Vertin betahistine 25mg bd S S S s
t.Tydol tapentadol Sos S S
t.Maxgalin m pregabalin 75mg bd S S S
t.Nexito escitalopram 10mg S S
c.Betacapt propanalol 5mg S S
t.Anxit alprazolam 0.5mg Hs S
t.Vasograin ergotamine Hs S S
Avamy nasal spray fluticasone Bd S S

10. S A 44 yr old F patient has severe headache, vomiting,neck pain radiating to
shoulder,giddiness,insomnia,blurred vision,freq urination,burning
micturition,lower back ache.Recently fount as HTNsive on T.AMLONG 5mg
O ESR was elevated CT shows B/L sclerosing mastoiditis
Septated maxillary sinuses
Patent osteomeatal unit
Deviated nasal septum to right
A patient was diagnosed with Cervical spondylosis,SHT,migrain,follicular
tonsilitis
P Planned for tonsillectomy.Pt can be treated with
analgesics,antibiotics,corticosteroids,antideprresnts,anxiolytics,antiemetics
and PPI