case 7 35 year old female with headache

on
A 35 year old female, resident of Nalgonda , farmer by occupation came to hospital on 19/9/22 with 

CHIEF COMPLAINTS
       Headache and neckpain since 6 months .
 Headache was on and off and associated with vomitings. She complaints of hearing loss and tinnitus in right ear and giddiness since 1 month.

HISTORY OF PRESENT ILLNESS 
     The patient was apparently assymptomatic 6months ago.The she had headache associated with neck pain and vomitings. 
She complaints of hearing loss and tinnitus in right ear and giddiness while head movement since 1 month. She has no history of fever or chills. No history of ear discharge.

PAST HISTORY
      No history of DM
      No history of HTN 
      No history of CAD , Asthma , epilepsy, TB 

FAMILY HISTORY 
        No History of DM , HTN ,CAD , TB , Asthma 

PERSONAL HISTORY
       Married
       Farmer by occupation
       Mixed diet 
       Normal appetite
       Normal bowel movement
       Normal micturition
       No known allergies 
 
GENERAL EXAMINATION 
       Conscious and coherent
       Moderately built
       Moderately nourished 
       No pallor
       No icterus
       No cyanosis, clubbing of fingers ,           lymphadenopathy, pedal oedema 
  
VITALS 
 Temperature - afebrile 
  Pulse rate - 90beats /minute
  Respiratory rate - 18/min
  BP  -120/80 mm of Hg
  SpO2 - 98%
  GRBS - 84 mg%

SYSTEMIC EXAMINATION
 CVS 
 No thrills 
 S1 S2 + 
 No cardiac murmurs

RESPIRATORY SYSTEM
Centrally located trachea 
Vesicular breath sounds 
No dyspnea
No wheezing 

ABDOMEN
Scaphoid shaped abdomen
 No tenderness
No palpable mass
 
CNS 
Conscious and coherent
Normal speech

INVESTIGATIONS 
TREATMENT

1.Tab. Zofer 4mg STAT 
2. Tab. PAN 40 PO OD
3.Tab . MUT PO OD
4.  Naproxene 250mg PO OD


PROVISIONAL DIAGNOSIS 
    Migraine headache 

      


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