65 yr old female patient came with complaint of giddiness

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 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

CHIEF COMPLAINTS-

C/o loss of hearing since 3 months 

C/o giddiness since 3 months 


HOPI- 

Patient was apparently asymptomatic 3 months ago. Then she developed giddiness of sudden onset, aggravated on lying down in supine position and changing positions from supine to standing or sitting position. Giddiness is not associated with nausea, vomiting, headache. 

H/o nocturia present 

H/o tingling sensations in the lower limbs

H/o hearing loss since 3 months 

No h/o trauma to the head

No h/o chest pain, shortness of breath, palpitations. 

No h/o fever, polyphagia, polydypsia 


PAST HISTORY- 

Known case of diabetes since 10 years and is on regular medication

Known case of hypertension since 10 years and is on regular medication

Not a known case of asthma, seizures, CAD, CVD

No h/o blood transfusions  


TREATMENT HISTORY- 

Diabetes- since 10 years 

Hypertension- since 10 years 


SURGICAL HISTORY- 

Patient had a left femur fracture 3 years ago and was treated with open reduction with internal fixation and she walks with a stick 


PERSONAL HISTORY-

Sleep- adequate

Appetite- normal

Diet- vegetarian 

Bowel and bladder movements- regular

Micturition- normal

allergies- nil 

Addictions- 

Alcohol- toddy occasionally 

Tobacco- No

Drug usage- No

Betel nut- No

Betel  leaf- No


FAMILY HISTORY- not significant 


MENSTRUAL HISTORY- 

Attained menopause 20 years back


PHYSICAL EXAMINATION-

A) GENERAL EXAMINATION-

Height- 

Weight-

Pallor- absent 

Icterus- absent

Cyanosis- absent 

Clubbing- absent

Lymphadenopathy- absent 

Edema- bilateral pedal Edema 



Malnutrition- absent 

Dehydration- absent 

Vitals-

Temperature- 97.5

Pulse rate- 86/ min

Respiratory rate- 18 cpm 

Blood pressure-

 left arm- 160/90mmHg, right arm- 170/90mmHg 

SpO2 at room temperature - 95%


SYSTEMIC EXAMINATION-

CVS- S1 S2 heard, no thrill, no murmurs 

RESP-  

dyspnoea- absent

 Wheeze-  absent 

Position of trachea- central

Breath sounds- Normal vesicular breath sounds

Adventitious sounds- absent 

ABDOMEN- 

Shape of the abdomen- obese

No tenderness

No palpable mass

No hernial orifices

No free fluid

Liver- not palpable 

Spleen- not palpable 

Bowel sounds- present 

CNS-

Level of consciousness- conscious 

Speech- Normal


INVESTIGATIONS- 





PROVISIONAL DIAGNOSIS- 

BENIGN PAROXYSMAL POSITIONAL VERTIGO


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