Dizziness under Evaluation

Hello everyone.. I am Sai Teja, an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties.



Here we discuss our individual patients 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-centred online learning portfolio and your valuable inputs on the comment box is welcome.


Here is a case i have seen

A 28yr male patient resident of oligonda came with complaints of  dizziness,lightheadedness,diplopia and vomiting since four days.H/o Trauma one week back due to sudden hit by tailoring machine.

Patient was apparently asymptomatic one week back, then he had a history of trauma due to sudden hit by tailoring machine following which he developed pain in lumbar region radiating to both legs, dizziness,light headedness,diplopia,vomitings and headache since 5 days.

No H/o loss of consciousness
No H/o involuntary movements
No H/o slurring speech and blurred vision
No H/o of seizures
No H/o weakness in limbs
No H/o bowel and bladder incontinence
No H/o syncopal attacks, palpitation, shortness of breath
No H/o fever, loose stools, cough, cold
No H/o tinnitus,ear pain and aural fullness

PAST HISTORY:-

      H/o bike accident two weeks back 
      H/o fall from height 14 years back

FAMILY HISTORY:-

  His Maternal grandmother has diabetes
  His mother and her two sisters are also diabetic 
  
MARITAL HISTORY:-

   Consanginous marriage 

PERSONAL HISTORY:-

  Diet:-Mixed
  Appetite:-Normal
  Sleep:-Sleep disturbances present
  Bowel and Bladder movements:-Normal

GENERAL EXAMINATION:-
  
       On examination the patient conscious,coherent,cooperative oriented to time,place and person and moderately built and well nourished.

Pallor:-Absent

Icterus:-Absent

Cyanosis:-Absent

Clubbing:-Absent

Lymphadenopathy:-Absent

Edema:-Absent

Temperature:-Afebrile at the time of presentation(10:00am) and his temperature is 102.5 degrees Fahrenheit at 7:00pm

Blood pressure:-130/90 mm of Hg on supine position and 110/80 mm of Hg on standing

Pulse:-70bpm in supine position and 90bpm in standing position

Respiratory rate:-20cpm


CNS:-

 HIGHER MENTAL FUNCTIONS:-
                    
         Patient is conscious,coherent and cooperative and oriented to time place and person
         

MOTOR SYSTEM:-
                   Rt.        Lt
Bulk:- 
 
       U/L. Normal. Normal
        L/L normal normal

Tone:-

     U/L.   Normal.  Normal
      L/L.  Normal.     Normal
Power:-

Shoulder
Deltoid.  5/5   5/5
Supraspinatus 5/5.      5/5
Infra spinatus    5/5.     5/5
Rhomboides5/5.      5/5
S. Anterior.  5/5.    5/5
P.major.        5/5.     5/5
Latismus dorsi.  5/5.  5/5
Elbow
Biceps.    5/5.            5/5
Triceps.    5/5.            5/5
Brachioradialis5/5.     5/5
Forearm and wrist:
ECR 5/5      5/5
ECU 5/5      5/5
ED.   5/5.      5/5
FCR 5/5      5/5
FCU 5/5      5/5
EPB 5/5      5/5
EPL 5/5       5/5
FDP 5/5       5/5
Abductor pollicis 5/5.   5/5
Adductor pollicis 5/5.  5/5
Opponens pollicis 5/5.   5/5
Lumbricals        5/5.      5/5

Hip girdle:
Iliopsoas 5/5     5/5
Adductor femoris 5/5     5/5
Gluteus medius 5/5       5/5
Gluteus  maximus5/5.     5/5
Hamstrings.         5/5.       5/5
Quadriceps femoris5/5.    5/5
Tib. Anterior.        5/5.          5/5
Tib.posterior.         5/5.         5/5
Peritonei.             5/5.           5/5
Gastronemius.     5/5.          5/5
EDL.                      5/5.           5/5
FHL.                       5/5.           5/5
EDB

REFLEXES:-    Right  Left

Biceps ++ ++
Triceps ++              ++
Supinator                    ++              ++
Knee                     ++              ++
Ankle                      ++              ++
Plantar                     F                  F

Superficial reflex:-
    
     Abdominal:-Present
     Corneal:-Present
     Conjunctival:-Present

Sensory:-      All the below sensations are normal 
                          
Crude touch 
Fine touch
Vibrations
temperature 
joint 
Tactile localisation
Two point discrimination and
Stereognosis are Normal



INVESTIGATIONS:-


RENAL FUNCTTION TESTS:-

              Urea:- 35
              Creatinine:- 1.1
              Uric acid:-4.7
              Serum sodium:- 141
              Serum Potassium:- 4.1
              Chloride:- 98
              Calcium:- 10.2
 
RBS:-221mg/dl

Fasting Blood Sugar:-139mg/dl

PLBS:- 203mg/dl

HbA1c:-6.8

PATIENT IS DENOVO DIABETIC


HEMOGRAM:-

            Hb:- 12.7
            TLC:- 12,300
            Neutrophils:-56
            Leukocytes:- 40
            PCV:-36.3
            MCV:-80.6
            MCH:-28.1
            MCHC:-34.9
            RDW-SD:-40.5
            RDW-CV:-13.2
            RBC count:-4.50millions/cumm
            Platelet count:-1.76lakhs/cumm
SMEAR:-
           
            RBC:- Normocytic Normochromic
            Platelets:- Adequate
            Haemoparasites:-No haemoparasites seen

ELECTROCARDIOGRAM:-

                                 This one is at 10:00am on 12/08/2020

This one is at 5:45pm on 12/08/2020

2D ECHO:-



CHEST X-RAY:-



C-SPINE:- AP&LATERAL



FUNDOSCOPY:-

  Normal fundus study and no evidence suggestive of pappiledema.

TREATMENT:-

INJ PAN 40mg/IV/OD

INJ ZOFER 4mg/IV/TID

TAB VERTIN 16mg/PO/TID

TAB PCM 650mg/SOS

TAB NAPROXEN 250mg BD

TAB METFORMIN 500mg BD

IV FLUIDS 1 UNIT NS with 1 AMP OPTINEURON IV OD@100ml/hr and 1 UNIT RL





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