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:
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
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