gm blog. Date:18-4-23

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, HTN, 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 : Nystagmus: present
       No ataxia present
       NFND, HMF intact.
       Speech:normal.
       No delusions or hallucinations
       Cranial nerve examination -intact
   MOTOR SYSTEM:
Bulk -N
Tone-N in upper and lower limbs
Power-grade: 5/5 in upper and lower limbs on                 both sides
Reflexes: superficial and deep reflexes are              present.
Cerebellum: Coordination -N
Gait:N
No involuntary movements.
     SENSORY SYSTEM: Normal

Investigations-



Provisional Diagnosis-
Giddiness Secondary to ?BPPV

Treatment-
T. Vertin 16mg PO/BD
T. Atenolol 25mg PO/OD
T. Pan 40mg PO/OD
T. Zincovit PO/OD
T. Zofer 4mg PO/SOS

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