General medicine (3)
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-44 year old female came to OPD with the complaint of giddiness on the same day of morning at 5:00(5am) complaints of vomitings.
October -18 ,2022.
44 year old female came to OPD with the complaint of giddiness on the same day of morning at 5:00(5am) complaints of vomitings.
Chief complaints:
Patients complaints of giddiness, vomiting and there is no headache, blurring of vision and nausea suspected.
History of present illness:
-No loss of consciousness
-patient had 2 episodes of vomitings in the morning of 16th October
-no bleed and mucus seen in vomiting
-no nausea, headache,and blurring of vision.
-no slurring of specch and no deviation of mouth
History of past Illness:
-k/c/o: hypertension since 4 years
-n/k/c/o: diabetes mellitus, tuberculosis, epilepsy,asthma, coronary artery disease
Treatment history:
No diabetes,htn since 4 years
Treatment with.. Tab: telma 40mg
No cad, asthma, TB
No known history of taking antibiotics, radiation chemotherapy,blood transfusion,and any surgeries.
Personal history:
-married
-occupation: daily labour.. stopped working four years ago
-non vegetarian
Bowel and bladder: regular
-micturition: normal
-no known allergies
-habbits: patient is having habit of consuming toddy occasionally
-no history of smoking, tobacco consuming,drugs,betel nuts and betel leaves
Family history:
No other family member has similar complaints
Menstrual history: age of menarche?
Menstrual cycles: duration of cycles by no of days bleedings?
Any gynaecology probs?
Physical examination:
-no pallor
-no cyanosis
-no icterus
-no clubbing of fingers
-no edema of feet
-no lymphadenopathy
-no malnutrition
-no dehydration
Vitals:
Temp:97.4f
Respiratory rate:16/min
Pulse rate:73/min
BP:170/90mmhg
Systemic examination:o
Cardiovascular system: no thrills,no cardiac murmurs
Cardiac sounds- s1,s2 positive
Respiratory system:
-no dyspnea
-no wheeze
-position of trachea-central
-breath sounds- vesicular
Abdomen:
Shape of abdomen-scalloped
Non tender
No palpable mass
Hernial orifice normal
Liver and spleen not palpable
No bowel sounds
Central nervous system:
Level of consciousness-conscious
Speech- normal
Signs of meningial irritation-a)neck stiffness
b) no kernigs sign
Provisional diagnosis:
Bppv(benign paroxysmal positional vertigo)
Investigations:
Mri brain
Carotid Doppler
ECG
Treatment
telma 40 mg
Vertin 16mg
pregaba
Ultracet
