45 FEMALE 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, investigations and come up with diagnosis and treatment plan

This is a case of 45 year old female Patient presented with chief complaints of 

giddiness since 2 months 

tinittus since 3 yrs

Left sided headache since 3 years 

HOPI : Patient was apparently asymptomatic 3 yrs back after which she developed giddiness associated with decreased hearing in the left ear, associated with vomitings occasionally ( 2-3 episodes / month )

H/o tinittus since 3 yrs

No H/o ear pain & discharge 

H/o Headache which is left sided , on & off since 3 yrs , associated with phonophobia, not associated with lacrimation and photophobia

C/o giddiness decreased with rest & medication ( Tab cinarazine )

H/o DNS surgery 1 yr ago.

5yrs ago patient had H/o weight loss , loss of hair, generalised body pains, loss of appetite, and was diagnosed with hyperthyroidism 5 years ago (used carbimazole 5 mg for 4 yrs & stopped since 1 yr )

H/o lower limb swelling till ankle 20 yrs ago & was told to be having ? Filariasis 

H/o palpitations (on and off)since 6 months

H/o decreased sleep since 4 months due to tinnitus 

No H/o chest pain, SOB, orthopnea, PND

PAST HISTORY:

H/o hyperthyroidism 

H/o hysterectomy 20 yrs ago i/v/o fibroid

N/k/c/o DM 2 , HTN, CAD, asthma, Epilepsy 

PERSONAL HISTORY:

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowel and bladder: normal

DAILY ROUTINE:

A saree weaver by occupation who wakes up at 5:30 am and does her daily morning activities and household work 

She has her breakfast at 8 am and then goes to work  comes back at 4 pm 

She usually has her lunch at 2 pm which includes chapathi and curry.

4pm to 9 pm she does hosehold chores and takes rest .

At 9 pm she takes her dinner and then sleeps at around 11 pm.

There is no change in daily routine.

On examination: 

Patient is conscious, coherent, cooperative 

No pallor , icterus, cyanosis, clubbing and lymphadenopathy.

Temp : 98.5°f

PR : 82 bpm

BP : 140/90 mm Hg (supine) — 130/90 mm Hg (standing)

RR : 18 cpm

GRBS : 102 mg/dl.

SYSTEMIC EXAMINATION:

Central Nervous system:

Higher motor functions- Intact 

Cranial nerve functions - Normal

Sensory system-Normal(fine and crude touch, proprioception,vibration)

Motor system. Right Left    

                    Power- UL 4/5 4/5

                                 LL 4/5 4/5 

                         Neck Normal 

                 Trunk muscles Normal  

              Tone- UL Normal Normal

                         LL Normal Normal 

          Reflexes- 

Superficial reflexes - Intact 

                             Plantar flexion extension

Deep tendon reflexes -

                           Biceps ++ ++

                           Triceps ++ ++

                         Supinator + +

                                Knee + + 

                             Ankle + +

Cerebellum : 1) Nystagmus - Absent 

                       2) Dysdiadochokinesia - absent 

                       3)Finger nose test - normal 

Dix Hallpike- Negitive.

CVS S1S2 heard

RS bilateral air entry present, NVBS

GIT :P/A Soft , NT 

INVESTIGATIONS:

CHEST X RAY:

ECG:

ENT REFERRAL:

Provisional diagnosis:

?MENIERE'S DISEASE WITH K/C/O HYPERTHYROIDISM SINCE 5 YRS.

Treatment:

Tab.Vertin 16mg/TID 

Tab.Tinnicar 20 mg/od