A 80 year old male with complaints of giddiness and vomiting

A 80 YR OLD MALE WITH GIDDINESS AND VOMITING
A 80 year old hypertensive male, resident of narketpally, labourer by occupation was brought to OPD on Thursday by his family with,
C/o : 1. Giddiness since 3 days
          2. Vomitings since 3days

Hopi :
Patient was apparently asymptomatic in the morning when he went to work 
He started having vomitings after his lunch, 4 episodes, sudden in onset, which was not associated with nausea, contained food content,  non projectile
Vomitings are followed by giddiness and weakness, headache is present. 
Weakness was generalised and was sudden in onset following the vomiting.
There is no diurnal variation in the weakness in the weakness of muscles
No fever, neck stiffness, abdominal pain and diarrhea.
No loss of movements, confusion, abnormality in speech 
No incontinence of bladder or bowel movement 
Past history :
Patient was diagnosed with hypertension around 2 years back on a routine check up
He is taking regular medication 
No H/ O diabetes mellitus, tuberculosis, asthma, epilepsy.
No H / O any trauma
No H / O surgeries

Personal history :
Diet - mixed
Apetite - normal
Bowel and bladder - regular
Consumes alcohol everyday - 90 ml
Smokes a beedi everyday 
No h/o Allergies

General examination :

Patient was examined after taking informed consent in a well lit room after he was comfortably seated 
Patient was conscious, coherent, cooperative and we'll oriented to time and place. 
Moderate built and moderate nourished 
No pallor, Icterus, Cyanosis, clubbing, pedal edema, Lymphadenopathy.




There are multiple dilated tortuous veins on anterior part of right leg

Vitals :
Pulse rate : 80 bpm, normal rhythm 
Blood pressure : 120/90 mm of Hg 
Respiratory rate : 14 cpm 
Temperature. : afebrile
CNS examination : 
Gcs - 15 /15 
Higher mental functions - 
Patient is conscious, oriented to time and place 
Memory is intact
 Speech and language normal 
Cranial nerve examination -
Nystagmus present....... 
Other cranial nerves intact 
Motor examination : 
               
                                      Right      Left 

Bulk                            normal      normal 

Tone -  upper limb    normal        normal 
             Lower limb     normal      normal 

Power - upper limb    5 / 5               5/5 
               Lower limb    5 / 5             5/5     

Reflexes - knee jerk : absent absent 
                   Ankle jerk : absent. absent 
                   Biceps : absent absent 
                   Plantar : absent absent 

Cerebellar examination - 
   
Finger nose test : no coordination 
Knee heel test : no coordination 
Dysdiadokokinesia : absent 

Nystagmus present 

Abdominal examination : 
Soft, non tender 
No organomegaly 
CVS examination : 
S1 and S2 heard 
No murmurs. 
Respiratory examination : 
Bae present 
Normal vesicular breath sounds 
Ent examination : 
Normal 

Investigations : 








Treatment : 

1) TAB. PROMETHAZINE 25 mg PO/TID
2) INJ. VERTIN 16mg PO/TID
3) TAB. AMLONG 5 mg PO/OD (8 am)
4) TAB. PANTOP 40 mg PO/OD
5) TAB. AUGMENTIN 625 mg PO/BD
6) TAB. THIAMINE 100 mg PO/BD
7) TAB. NAPROXEN 250 mg PO/BD
8) Vitals monitoring - 4th hrly
9)Grbs fourth hourly

Popular posts from this blog

MEDICINE CASE DISUSSION

Image
A 37 YEAR OLD FEMALE WITH FEVER, HEADACHE, BODY PAINS, SHORTNESS OF BREATH AND DRY COUGH  N. SAIKRISHNA  MBBS 8th semester Roll no:101 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .   I’ve 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, investigations, and come up with diagnosis and treatment plan. Following is the view of my case ... CASE: A 37 year old fe...
Read more

General medicine assaingment

Image
N. Sai Krishna Medicine assaingnment  MEDICINE BLENDED ASSIGNMENT May 24,2021 I have been given the following cases 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, investigation and diagnosis and come up with the treatment plan. This is the link of questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the medicine assignment based on my comprehension of the cases. Pulmonology   Case 1 What is the evolution of the syptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Evolution of symptomology: 20 yrs back-First episode of shortness of breath(lasted for 1 week during January)and continued in the same pattern for 7 years ...
Read more

40M,Easy fatigability 1yr

Image
A 40 year old male came with complaints of easy fatigability since 1 year (on & off) Shortness of breath since 5-6 months HOPI: Pt was apparently asymptomatic 1 year back he then noticed having easy fatigability - feeling tired on doing minimal work  insidious in onset and gradually progressive. C/o shortness of breath since 5-6months insidious in onset and gradually progressive grade ll to grade lll (now) C/o decreased appetite since 1 month, Normal urine output C/o blood in stools (on & off) since 1 year with fresh blood streaks. No h/o constipation, difficulty on passing stools No c/o fever ,pain abdomen,cold,cough, burning micturition, vomitings,nausea,blood in urine. No h/o chest pain,orthopnea,PND, palpitations, giddiness, sweating. C/o generalized weakness of body since  5-6 months. Not a k/c/o DM,HTN,CVA,CAD, Epilepsy, Thyroid diseases, Bronchial Asthma. Personal history: Ocassionally Alcoholic and stopped 10years back  Tobacco smoking since 20 years No h/...
Read more