65/F with giddiness

12/09/2023

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Khushi Tulsyan, Intern

Roll no. 49

Unit Incharge - 

Location - Female Ward 8

DOA - 12/09/2023

Ward - Female Medical ward 8

Pt came with 

-c/o giddiness since 1 yr

-c/o headache since 1 yr

Pt was apparently asymptomatic 1 yr ago then she developed giddiness which is associated with sweating palpitations 

C/o headache which is throbbing in temporal region and not associated with photophobia phonophobia and nausea

No h/o giddiness aggravating with neck movements earache and tinnitus 

No h/o vomiting fever loose stools pain abdomen cough cold

No h/o slurring of speech limb weakness deviation of mouth

No h/o sob chest pain palpitations orthopnea pnd

PAST HISTORY-

K/C/O DM 2 since 1 yr (on tab metformin 500 mg) ,HTN since 1 yr (on omlesartan 20 mg )and CVA since 1 yr (on atrozio gold (atrovastatin clopidogrel and aspirin)) 

(CT scan - B/l periventricular white matter hypodensities ? Chronic Ischemic changes 

Multiple small calcific foci in the frontal and b/l parietal region)

N/k/c/o  TB , Epilepsy, CAD

PERSONAL HISTORY-

Diet - Mixed

Appetite - Normal

Bowel and Bladder movements- Regular

Sleep - Adequate 

Addictions - None

FAMILY HISTORY-

Not significant

GENRAL EXAMINATION-

Pt is c/c/c well oriented to time place and person 

No signs of pallor icterus cyanosis clubbing lymphadenopathy edema 

Temp - Afebrile

PR - 78bpm

RR - 18cpm

BP - 110/80mmhg

Spo2 - 98RA

GRBS - mg%

Clinical Pictures-

SYSTEMIC EXAMINATION-

CVS -

S1 S2 +

No thrills felt

No murmurs heard

RS -

B/l air entry +

Position of trachea central

No wheeze or rhonchi

P/A-

Shape - scphaoid

No tenderness or organomegaly present

CNS-

She is conscious coherent and cooperative 

No signs of meningeal irritation 

Motor System-

GCS 15/15 - E4V5M6

Power-

                           R.          L. 

U/l                     5/5.       5/5

L/l.                    5/5.       5/5

Tone-

U/l.                   N.          N

L/l.                    N.          N

Reflexes-

B.                      +.            +

T.                       +            +

K.                       -             -

A.                      -              -

Plantar        Flexor.    Flexor

PROVISIONAL DIAGNOSIS-

Giddiness under evaluation ?Hypoglycemia

H/o CVA 1 yr ago

INVESTIGATIONS-

CUE -

Alb - Nil

Sugar - Nil

Pus cells - 1-2

Epithelial cells - 2-3

Rbc - nil

HEMOGRAM-

Hb - 8.4

Tlc - 5900

Platlets - 2.88

Rbs - 117

Blood urea - 42

Sr . Creat - 1.5

USG -

B/l Grade 1 RPD changes

Grade 1 Fatty liver

2D echo -

Trivial TR

No MR AR

No RWMA 

No AS/MS sclerotic

Good LV systolic function

Diastolic dysfunction

No 

Ecg-

Chest X-Ray

PLAN OF TREATMENT-

Tab Ecosprin PO/OD 

Tab Metformin 500 mg

Tab Omelsartan 20 mg