A 38yr old female with giddiness and vomiting since 15days
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A 38yr old female who is a resident of Thirumalagiri,daily wage worker came to medicine OPD with
CHIEF COMPLAINTS:
C/o giddiness since 15days
C/o vomitings since 15days
C/o low backache since 1year
HISTORY OF PRESENTING ILLNESS:
Patient was apparently alright 15days back then she had giddiness which is insidious in onset,gradually progressive,has positional influence and giddiness occurs on change in position of head and during walking. Associated with vomiting which is non bilious,non projectile and food as content.
H/o low backache since a yr,insidious in onset,gradually progressive and only present when lying on supine position,no aggrevating and relieving factors.
B/l LL pain which is dull aching type,radiating from knee to ankle.
H/o cold intolerance,decreased appetite since 20days.
No H/o weight loss / menstrual irregularities / chest pain / palpitation / syncopal attacks
H/o headache since 15days,diffuse, no h/o photophobia and phonophobia ,associated with giddiness episodes
H/o right ear discharge since long time
PAST HISTORY:
Not a known case of HTN,DM2 ,TB,Epilepsy,Asthma,CVA,CAD
PERSONAL HISTORY:
Moderately built and nourished
Diet-mixed
Appetite-normal
Sleep -adequate
Bowel and bladder movements-regular
No addictions
FAMILY HISTORY:
No significant family history
GENERAL AND PHYSICAL EXAMINATION:
Patient is conscious,coherent,cooperative
No signs of pallor,icterus,cyanosis,clubbing,edema,lymphadenopathy
VITALS:
Temperature-afebrile
PR-76bpm
BP-110/70mm hg
RR-19cpm
CVS examination:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Per Abdominal examination:
Soft , non tender
bowel sounds heard
CNS examination:
Nystagmus-absent
Head impulse-negative
Romberg’s -negative
Fistula test-negative
Dix-hallpike-can’t be performed I/V/o neck pain and vomitings
Cerebellar signs-negative
Tone: Rt Lt
UL N N
LL N N
Power:
UL 5/5 5/5
LL 5/5 5/5
Reflexes:
B ++ ++
T + +
S - -
K ++ ++
A + +
Pl F F
COURSE IN HOSPITAL:
A 38 yr old female with above mentioned complaints has been presented to medicine OPD and upon admission necessary investigations were done.
Upon admission patient was taken for ENT cross consultation I/V/o giddiness and right ear discharge and they advised pure tone audiometry and diagnosed as moderate conductive hearing loss of right ear and advice followed.
PURE TONE AUDIOMETRY:
TREATMENT:
1)Tab.Vertin 16mg TID
2)Candibiotic ear drops
3)Tab.Hifenac-p po/bd
4)Tab.Pan 40mg po/od
5)Tab.Neurokind-k po/hs
6)Tab.Gabapentin 100mg
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