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Case History :
80 year old male who is a farmer by occupation came to casualty on 06-01-22 with
Chief Complaints :
1. Vomiting 2 episodes since morning
2. Giddiness since morning .
History of Present Illness :
Patient was apparently asymptomatic until today morning, then he developed
- Vomitings - 2 episodes sudden in onset, bilious, non projectile type with food as contents.
- Giddiness - sudden onset aggravated with movements or sitting up, swaying while walking is present, associated with headache, nausea and vomiting.
- Not associated with pain abdomen, fever, loose stools.
- No history of loss of consciousness, seizures, diplopia, blackouts, chest pain, constipation, sweating and palpitations, earache, aural fullness or discharge, tinnitus
- No complaints of weakness, tingling or numbness of limbs, difficulty in chewing, swallowing, deviation of mouth
- No bowel and bladder incontinence.
Past History :
- Patient is a known case of Hypertension since 4 years and is on medication Tab. Atenolol 50 mg
- He is not a known case of Diabetes mellitus, Asthma, Tuberculosis, Epilepsy, Coronary Artery Disease
Personal History :
Diet- mixed
Appetite- normal
Bowel and bladder movements- regular
Sleep- adequate
No known allergies
Addictions : Alcohol intake since 40 years - 3 times/week 90 ml
Smoking since 40 years - 1 packet/day
Family history : Not Significant
General Examination :
-Patient is Conscious, coherent and cooperative.
-No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
Vitals :
Temperature - Afebrile
PR- 68 bpm
RR- 14 cpm
BP- 120/70 mmHg
SpO2- 99% at RA
GRBS- 132 mg/dL
Systemic Examination :
CVS : S1S2 heard, no murmurs
RS : BAE+, NVBS+
P/A : Soft, Non-tender
CNS :
Patient is well oriented to time, place, person
Higher mental functions:
- Memory : recent, remote intact
- Speech: Normal
Cranial nerves: Intact
Motor system :
Right Left
Tone : Upper limb Normal Normal
Lower Limb Normal Normal
Power : Upper limb Normal Normal
Lower Limb Normal Normal
Reflexes : Biceps jerk Absent Absent
Triceps jerk Absent Absent
Supinator jerk Absent Absent
Knee jerk Absent Absent
Ankle jerk Absent Absent
Tone- Normal in bilateral upper and lower limbs
Sensory system: crude touch ,pain, temperature, fine touch, joint position, proprioception are normal in all dermatomes
GCS: 15/15
Cerebellum:
Finger nose test - incoordination is seen
Knee heel - incoordination is seen
No dysdiadochokinesia.
Nystagmus is present in both horizontal and vertical gaze.
Provisional Diagnosis :
Giddiness under evaluation (?PCA stroke/ ? BPV)
Investigations :
Hemogram on 6/01/2022:
Hemogram on 7/01/2022:
CUE:
PT,APTT,INR:
ECG on 7/01/2022:
ECG on 8/01/2022:
USG ABDOMEN:
MRI BRAIN:
ENT Referral :
Treatment :
1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID
2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD
3) INJ. PANTOP 40 mg IV/BD
4) INJ. ZOFER 4 mg IV/TID
5) TAB. PROMETHAZINE 25 mg PO/TID
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