A 35 year old female with headache and hearing loss

 Sep 26th

Hello, I am Y.N.Indu Vaishnavi,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio

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


CHIEF COMPLAINTS

Headache and neck pain since 6 months .
Headache was on and off and associated with vomiting. She complaints of hearing loss and tinnitus in right ear and giddiness since 1 month.

HISTORY OF PRESENT ILLNESS 

     The patient was apparently asymptomatic 6months ago.The she had headache associated with neck pain and vomiting. 
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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