A 35 year old female presented to OPD with headache and hearing loss

CHIEF COMPLAINTS

  She had Headache and neck pain 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 asymptomatic 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