December 5th 2022
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A 70 yrs old female ,resident of miryalaguda came to opd with cheif complaints of headache since 6 months.
CHIEF COMPLAINTS
Headache since 6 months
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 months back, patient fell on the ground while doing some work due to obstacle in her way this is the incident that occurred 9 months before and 2 months of that incident she developed Headache which was insidious in onset and intermittent in nature ,diffuse type with no aggrevating and relieving factors.
Headache is not associated with fever, seizures,vomitings, giddiness,loss of consciousness,weakness in upper limb and lower limb
Patient also had left and right knee pain since 3 months , left knee pain is more than right knee pain.
Generalised weakness since 1 month
PAST HISTORY
No similar complaints in the past
Not a known case of HYPERTENSION, DIABETES MELLITUS, ASTHMA, EPILEPSY, TB,Cardiovascular disease
Underwent Bilateral cataract surgery
History of injury to Head on right side due to falling 9 months back
No history of any other surgeries
PERSONAL HISTORY
Diet is mixed
Appetite is reduced
Sleep is disturbed (due to Headache)
Bladder movements are regular
Constipation is present (passage of 1 stool per 3 days)
No Addictions
FAMILY HISTORY
Not significant family history
TREATMENT HISTORY
Used medication for Headache and Knee pain
GENERAL EXAMINATION
Patient is conscious,coherent and cooperative,well oriented to time,place and person.
No Pallor, cyanosis, clubbing,icterus generalised lymphadenopathy,Edema
Vitals:
Temperature is afebrile
Blood pressure110/70mmHg
Pulse rate 75 bpm
Respiratory Rate 16 Cycles per min
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM:
S1,S2 heard
No murmurs
RESPIRATORY SYSTEM:
BAE- present
No wheeze
Trachea position -Central
Breath sounds -vesicular
ABDOMINAL EXAMINATION
Abdomen is soft and non tender
CENTRAL NERVOUS SYSTEM
No focal and neurological deficits
HMF -Normal
CNS Examination
Higher mental functions:
Oriented to time,place,person
Memory : Immediate,recent, remote intact
Speech: slurred
No delusions or hallucination
Cranial nerves:
1- not tested
2- Pupillary reflex present in right side absent in left side
3,4,6- No restriction of movement of eye
5-normal( muscles of mastication+sensations of face)
7-Normal, wrinking of forehead seen, able to blow up cheeks
8- Normal hearing
Motor examination:
Tone -normal in both limbs
Power-. Right Left
Upper limb 5/5 5/5
Lower limb 5/5 5/5
Reflexes :
Biceps: Right++
Left: ++
Triceps: Right++
Left: ++
Supinator: Right++
Left: ++
Knee: Right: ++
Left: ++
Ankle: Right: ++
Left: ++
Cerebellum examination:
Able to do finger nose test.
Able to do dysdiadokinesia
Gait: Not able to walk in straight line(ataxic gait)
Romberg's sign : positive (loss of balance on closing eyes)
Meningeal signs : neck stiffness is present
HAEMOGRAM
LIVER FUNCTION TESTS
BLOOD UREA
BLOOD SUGAR
ERYTHROCYTE SEDIMENTATION RATE
SERUM CREATININE
ECG
HEADACHE UNDER EVALUATION
TREATMENT
TAB ULTRACET QID
TAB PAN 40 Mg OD
Inj optineuron 1Amp /100ml
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