Case discussion on 70 year old 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
70 year old female, resident of Mothkur was brought to casuality with a/h/o fall. She has had giddiness since 1 week, similar episodes of falls- 3 episodes since 1 week.
The attenders give complaints of altered sensorium since 8 hours, deviation of angle of mouth since 8 hours, slurring of speech since 8 hours.
HOPI: Patient was apparently asymptomatic 1 week ago, then she developed giddiness which was sudden in onset and gradually progressive. It was not associated with hearing loss, tinnitus,postural fall or aggravation with position change.
H/o fall, 3 episodes since 1 week. The falls were associated with external injuries, with one time, leading to suturing done on chin outside.
Since 8 hours, the patient has had altered sensorium and is irritable. She also has deviation of angle of mouth and slurring of speech.
No h/o fever, cough, shortness of breath, vomiting, loose stools, pain abdomen
Past history: k/c/o seizure disorder since 15 years, on Tab. EPTOIN 200 mg PO/BD
15 years back, Patient started having episodes of seizures where she would have an aura and then fall with thrashing of limbs. The episode was associated with loss of consciousness for 5 minutes and foaming at mouth. There would be confusion after the episode of seizure. She has been using medication since 15 years but would still have occasional episodes. The last episode was 2-3 months ago.
Not a k/c/o DM, HTN,TB, asthma, CAD,CVA
H/o Left femoral fracture, treated by placing a femoral nail
Personal history:
Takes mixed diet,
Normal appetite
Bowel and bladder are regular
Sleep adequate
Occasionally drinks toddy or beer (once in a month)
No Allergies
No Significant family history.
O/E:
Patient is drowsy
Pallor- Absent
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- Absent
Temp: 96.8°F
PR: 82 bpm
RR: 18 cpm
BP: 140/90 mmHg
SpO2: 98%
GRBS: 115 mg/dl
CVS: S1S2 +
RS: BAE, NVBS
P/A: soft, non tender
CNS:
Patient is drowsy
On examination of the motor system, tone is normal in both upper and lower limbs and power is -4/5 b/l. The Biceps and knee reflex are +2 and plantar reflex shows an extensor response.
There were no signs of meningeal irritation
Dix hallpike negative
Provisional diagnosis:
Giddiness under Evaluation: ?BPPV, ?Vestibular neuritis, k/c/o seizure disorder since 15 years
Investigations:
USG abdomen:
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