Case discussion on 65 year old female with giddiness
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.
CASE DISCUSSION:
65 year old female, resident of Shakapuram village in Nalgonda district and a housewife came on 15/4/23 with complaints of giddiness since 4 months.
History of presenting illness:
Patient was apparently asymptomatic 4 months back when she started to develop episodes of giddiness, which led to a fall at home leaving her unconscious for a few seconds. She had 2 more similar episodes 3 months back and the most recent episode, which was 2 months ago caused her a fracture in her right hand.
The episodes of giddiness were associated with loss of consciousness for around 3-5 seconds. There was no h/o of any ENT bleed, any seizures, vomitings, headache or thinking/memory disturbances after the falls. She regained consciousness in about 5 seconds and did not lose it again at any time after the fall, in between the episodes.
She also complains of giddiness while lying down, which lasts for 2 minutes and is relived automatically. Postural variation +. For these symptoms,the patient has been using medication since 2 months. Tab. PROCHLORPERAZINE 5 mg PO/OD
No c/o nausea, vomiting, loose stools, fever, cough or cold
No c/o motion sickness,chest pain, palpitations or shortness of breath
No h/o postural drop, ataxia
No h/o any major trauma to head
Past history:
There were no similar complaints in the past.
Patient is a k/c/o Hypertension since 30 years, on regular medication of Tab. ATENOLOL 50 mg PO/OD.
Not a k/c/o Diabetes mellitus, asthma, TB,epilepsy, CAD, arrhythmia, thyroid dysfunction.
H/o hysterectomy done 40 years back
H/o Bilateral knee replacement 10 years back.
H/o 1 PRBC blood transfusion done 10 years back
Personal history:
Takes mixed diet,
Normal appetite
Bowel and bladder are regular
Sleep adequate
No Addictions
No Allergies
No Significant family history.
General Examination:
Patient is conscious, coherent and cooperative.
On examination, there are no signs of pallor, icterus, cyanosis, clubbing, koilonychia, generalized edema or lymphadenopathy.
Sensory examination:
Crude touch, pain ,temp, fine touch, joint position, proprioception are normal in all dermatomes in upper and lower limbs.
Cerebellum examination:
Able to do finger nose test.
No dysdiadokinesia
No rebound tenderness
No ataxia
Rombergs test: Negative
No fall/swaying with patient's eyes closed. Romberg test: NegativeAutonomic Nervous System:
No postural hypotension
No bladder and bowel incontinence
No sweating abnormalities
Meningeal signs:
No meningal signs like Brudzinski or Kernig sign were positive
Gait: Normal
Provisional diagnosis:
Giddiness under Evaluation
Investigations (15/4/23):
Plan of care:
1) Tab ATENOLOL 50 mg PO/OD
2) Tab PROCHLORPERAZINE 5 mg PO/OD
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