A 60/F WITH COMPLAINTS OF GIDDINESS AND HEADACHE
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Unit 6:Case admitted in female ward on 6/2/2021.
Interns
K.Divya Rachana
K. Nikhil reddy
M. Swarna
B.Manivarma
Juveria
Dr. Vinay(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr.Praveen Naik( asst.proff)
Here is a case we've seen-
A 60 YEAR OLD FEMALE PATIENT, RESIDENT OF NALGONDA,FARMER BY OCCUPATION CAME WITH COMPLAINTS OF-
GIDDINESS SINCE 4 DAYS
NECK PAIN SINCE 6 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 DAYS AGO,THEN SHE HAD A FALL FOLLOWING WHICH SHE HAD LOSS OF CONSCIOUSNESS FOR 5-10 MIN AFTER WHICH SHE WOKE UP ON HER OWN.NO COMPLAINTS OF INVOLUNTARY MOVEMENTS DURING THE EPISODE. AFTER THE FALL PATIENT HAD COMPLAINTS PF HEADACHE.NO NAUSEA, PHOTOPHOBIA, PHOTOPHOBIA, BLURRING OF VISION.THEN SHE WENT TO A LOCAL HOSPITAL WHERE SHE WAS DENOVO DIAGNOSED AS HYPERTENSION AND DIABETIS MELLITUS.HER BP WAS 200/100 WHEN SHE WENT TO THAT LOCAL HOSPITAL (?? HYPERTENSIVE URGENCY).
SHE ALSO HAD PAIN IN THE LEFT SIDE OF CHEST WHICH WAS NOT RELIEVED BY MEDICATION
PATIENT ALSO COMPLAINED OF NECK PAIN WHICH IS DRAGGING IN TYPE NOT ASSOCIATED WITH NAUSEA,NO AGGRAVATING AND RELIEVING FACTORS AND NO RADIATION.
NO COMPLAINTS OF PALPITATIONS AND SYNCOPAL ATTACKS.
NO COMPLAINTS OF PEDAL EDEMA, ABDOMINAL PAIN, ABDOMINAL DISTENSION.
NO COMPLAINTS OF SHORTNESS OF BREATH, ORTHOPNEA,PND.
NO COMPLAINTS OF BURNING MICTURITION.
NO COMPLAINTS OF CONSTIPATION,LOOSE STOOLS
DENOVO DIAGNOSED AS HTN 2 DAYS AGO BY A LOCAL DOCTOR FOR WHICH SHE'S ON TAB AMLONG 10 MG OD
DENOVO DIAGNOSED AS DM 2 DAYS AGO FOR WHICH SHE'S ON TAB GLIMI-M1 OD
SHE CONSUMES VEGETARIAN DIET WITH NORMAL APPETITE.
SHE HAS REGULAR BLADDER AND BOWEL MOVEMENTS
SHE DOESN'T CONSUME ALCOHOL
SHE ISN'T A SMOKER.
NO H/O SIMILAR COMPLAINTS IN FAMILY
ON GENERAL EXAMINATION-
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
PALLOR IS PRESENT
NO ICTERUS, CYANOSIS, CLUBBING,KOILONYCHIA,PEDAL EDEMA, LYMPHADENOPATHY
TEMP-AFEBRILE
BP-120/60 MM OF HG
PULSE RATE-78 BEATS PER MIN
RESPIRATORY RATE-16 CPM
SPO2-98% AT ROOM AIR
GRBS-165 MG/DL
CVS-S1,S2 HEARD
NO MURMURS
RS-BAE+,DECREASED BREATH SOUNDS IN LEFT SSA
P/A-SOFT, NON TENDER, SCAPHOID,NO ORGANOMEGALY
CNS-
CONSCIOUS
SPEECH-NORMAL
NO SIGNS OF MENINGEAL IRRITATION
CRANIAL NERVES,MOTOR SYSTEM AND SENSORY SYSTEM-NORMAL
REFLEXES- RT LT
BICEPS 2+ 2+
TRICEPS 1+. 1+
SUPINATOR. - -
KNEE 2+ 3+
ANKLE - -
PLANTAR mute mute
POWER- RT LT
UL 5/5 5/5
LL 5/5 5/5
CEREBELLAR SIGNS - ABSENT
PROVISIONAL DIAGNOSIS-
HYPERTENSIVE EMERGENCY WITH DENOVO DM+,HTN+
TREATMENT-
DAY 1-
SALT RESTRICTED DIET
TAB AMLODIPINE 5 MG/PO/OD
INJ OPTINEURON 1 AMP IN 100 ML NS/IV/OD
INJ ZOFER 5 MG SOS
DAY 2-
TAB AMLONG 5 MG/PO/BD
TAB METFORMIN-SR 500 MG/PO/OD
