22 year old female presented with fever and headche since 10days

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A 22 year old female who is a farmer by occupation presented with the complaints of  

fever since 10days 

headache sine 10days   

acute urine retention since 10days 

 

 

 

 

 

 cheif complaints ;  

 

patient was apparently asymptomatic 10days back, then she complaints of headache diffuse in region , gradual in onset, dragging type, radiating to neck, it aggravated on talking rotating the head , relieved on taking medication. it is associated with nausea 

 

patient also gave history of fever since 10days which is high grade type associated with chills and rigors, gradual in onset, continous in nature, relieved on medications 

 pt complaints of vomitings 2 to 3 episodes associated with nausea, with food particles as contents,not associated with any blood 

pt complaints of  acute urinary retention  , able to feel fullness of bladder , not able to pass urine, relieved after passing foleys catheter 

 

 

 

 past history ; not a k/c/o DM, HTN,  TB, asthma, epilepsy, CVD,CVA 

 

 

personal history  

 

diet - mixed 

appetite - decreased 

bowel and bladder - irregular and constipation+ 

sleep - inadequate 

allergies  - no known allergies 

addiction - no addictions 

 

 

 Family history - insignificant 

 

 

 

 

 

 general examination  

  

No pallor 

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy 

No pedal odema 

 

 

 

 

vitals  

 

temperature - afebrile 

bp - 100 /60mmhg 

pulse - 82bpm 

respiratory rate 16cyclespermin 

 

  

 

 

 

 

 

CVS - S1,S2 heard 

 

Respiratory system - BAE+, NVBS+ 

 

PER ABDOMEN - soft, non tender 

 

 

 

 CNS EXAMINATON  

 

 

patient is conscious 

 

speech - normal  

 

  

reflexes - right       left

 

 

 B             absent     absent

 

T                   1+         1+

 

S                   1+           1+

 

K                  2+           2+

                  

A                 1+             1+
 

                

 

 

 

POWER            right        left  

 

 

upper limb          5/5          5/5

 

lower limb          5/5           5/5

 

 

TONE            right       left  

 

 

upper limb       5/5         5/5

 

lower limb         5/5        5/5

 

 

 Meningeal signs  - 

No neck stiffness

Kernigs - negative

Brudzinski sign - negative

 

 

Provisional Diagnosis - 

 Meningitis ?

Transverse myelitis ?