23 yr old female with fever headache vomiting and inability to pass urine since 5days

 February 17, 2022

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Khushi Tulsyan

Roll no. 75

A 23 yr old female farmer by occupation presented to the opd with chief complaints of headache, fever ,lethargy(since 10 days) inability to urinate (since 7 days) and vomiting with sputum (since 5 days). 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back. Then she had headache fever  chills and rigors.Fever was gradual in onset continuous association with rigors and chills and relieved on medication. Headache is diffuse mainly in the occipital region sudden in onset dragging type and radiating towards neck. It is aggravated on conversing , rotating head and was relievd with medication.It is associated with phonophobia and there is no history of nausea and photophobia.Vomiting was 2-3 episodes and is projectile bilious and has mucus in it and it non blood tinged. After two days she also had acute urinary retention and also was constipated.She could feel the bladder full and feel the pain but could not pass the urine whole night.She went to local RMP there he prescribed her medications and also attached the foleys catheter through which was able to urinate and IV injection was given for vomiting which was then subsided.

 She had a 2 day stay in the hospital. Then she was discharged. After that she again had urinary retention  headache and a brief episode of sudden loss of awareness, rolling her eyes upwards and tightly clenching her fist(which lasted for 5 mins on 13-02-22) and she doesn't have any memory of it.There was no history of any previous such episodes

 She presented to our casuality. 

She shows decrease in weight since the onset of symptoms. 

No history of urinary incontinence. 

No neck stiffness. 

No tingling sensation and numbness in both limbs. 

PAST HISTORY:

She is not known case of hypertension, diabetes, leprosy, epilepsy, aastha, ckd, cad, tb. 

History of Lower segment caeserean section 1.5 yrs back. 

PERSONAL HISTORY:

Diet- Mixed

Appetite - Decreased since 10 days

Bladder and bowel movements - Decreased since 7 days

Sleep - Decreased since 10 days

Addictions - no 

Allergies - no

MESNTRUAL HISTORY-

Menarche - 14 yrs

2-3 days 2 pads /day.

FAMILY HISTORY:

No significant family history. 

GENERAL EXAMINATION:

Patient is examined under well lit room and adequate ventilation with her consent taken

Patient is conscious , coherent and cooperative well orientated to time, space and person. She is moderately built and well nourished. 

No visible icterus, cyanosis, clubbing, lymphadenopathy, edema. 

Pallor is present

VITALS:

Temperature: febrile

Pulse: 110bpm

Respiratory rate: 14cpm

Blood pressure: 100/60 mm Hg

SpO2 at room air: 97%

GRBS: 133mg/dl

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard ,no murmurs 

Respiratory system:

Central position of trachea 

Vesicular breath sounds

No wheeze,no dyspnoea

Abdomen:

Scaphoid shape 

No tenderness

No palpable masses

Bowel sounds present

Central Nervous System:

No focal neurological defecits is present.

Neck stiffness:- No 

 Kernig sign :- No

    Reflexes        Right        Left

   Biceps.        Absent.    Absent 

   Triceps             1+              1+

  Supinator.         1+.             1+

   Knee.                2+.             2+

   Ankle.               1+.             1+

   Plantar.           Mute.        Mute

     

    Tone :-         Right.        Left

 Upper limb.      Normal.  Normal

Lower limb.      Normal.   Normal 

   Power:-        Right            Left

 Upper limb.     5/5.               5/5

 Lower limb.      5/5.              5/5

- No finger nose in coordination 

- No knee - heel in coordination

 INVESTIGATIONS:

CBP-

All the counts were in normal range

ECG-

MRI-

OPHTHALMOLOGY REFERRAL REPORT-

Bilateral papilloedema - early stage

LUMBAR PUNCTURE-

Sugars and protiens were in normal range

No trace of rbc present

Wbc - 25 cells were present - all were lymphocytes. 

USG-

All looks normal

PROVISIONAL DIAGNOSIS-

? Tranverse myleitis 

PLAN OF TREATMENT:

Inj dexa

Inj pantoprazole

Inj optineuron

Inj ceftriaxone