This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.
DEIDENTIFICATION -
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CASE DISCUSSION -
60 year old female homemaker by occupation came to the casualty with C/o giddiness since last 4 hrs.
HOPI -
Patient was apparently asymptomatic till 12:00 a.m. today, then she had sudden onset of vertigo with vomiting episodes
Vomitings- 2 episodes, non projectile, non bilious, contain food particles as content.
No H/o tinnitus, nystagmus, diplopia
No H/o trauma
Fever -nt
Cough -nt
Cold -nt
Palpitations -nt
Headache -nt
SOB - nt
Past History -
K/c/o Hypertension- On medication(Atenolol 25mg)
Not a k/c/o DM, CVA, CAD, TB, Epilepsy.
H/o Rt. Open simple nephrectomy done under GA 2 months back i/v/o Right Non Functional Kidney with Right Gross Hydronephrosis.
Hysterectomy done 18 years ago i/v/o Fibroids.
Personal History -
Married
Occupation- Homemaker
Diet: mixed
Appetite: normal
Bowel and bladder : Normal
Addictions: Nil
Family History -
No similar complaints in the family.
General Examination -
Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
She is conscious, coherent and cooperative.
Built & nourishment-Moderate
No pallor
No cyanosis
No icterus
No clubbing
No edema
No lymphadenopathy.
Systemic Examination -
CVS :
S1 S2 present
No murmurs
RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard
ABDOMEN:
Shape of abdomen: scaphoid.
Soft, non tender, no organomegaly present.
No rigidity or guarding.
CNS :
NFND, HMF intact
Reflexes - Normal
Investigations-
T. Vertin 16mg PO/BD
Provisional Diagnosis-
Giddiness Secondary to ?BPPV
Treatment-
T. Atenolol 25mg PO/OD
T. Pan 40mg PO/OD
T. Zincovit PO/OD
T. Zofer 4mg PO/SOS
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