27 year old male with c/o headache
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General examination:-
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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
Case history:
Cheif complaints:
.A 27yrs old male came to casuality with c/o headache
and giddiness on and off since 3yrs
HOPI:
Patient was apparently asymptomatic 3yrs back then he sustained head injury RTA (bike vs bike). He was presented to hospital with swelling over left occipital region and seizure like activity there was loss of consciousness for 1hr not associated with ear or nose bleeding, vomiting .where they done
CT brain and was told to be normal.
And from then he has been having episodes of occipital and parietal region headache , giddiness,palpitations, sweating, and left upper quadrant abdominal pain .
He discontinued intermediate 1st yr 10yrs back due to family health problems and since then he is helping his father in their printing shop . His father has 3 brothers.His 2 uncle's were expired and his father expired 4yrs back due to some cardiac problems.
2019: He was met with RTA in dec 2019.
2020: After 2months of RTA i.e in Feb 2020 he lifted heavy weights (house shifting) of his uncle using stairs and after that he got his 1st episode of dragging type of pain in parietal region, radiating to neck pain,difficulty in breathing with tachycardia, giddiness,sweating anxiety for 10 to 15mins.
Pt didn't particularly mention about Freqency but used to experience this kind of episodes when ever lifting heavy weights or climbing staris / on exertion.
2021 : Episodes frequency decreased.
2022:He got affected with Covid in Jan 2022.
Post covid patient again experienced episodes of headache and giddiness from March episode is sudden in onset again with sweating, difficulty in breathing with palpitations for 10mins.
Next episode after 1week of previous and went to cardiologist who gave some medication Tab Proponolol 20mg
Frequency of episodes decreased to 1 episode per month .
Again aggrevated in 2022 november associated with giddiness Used same medication whenever gets episodes.
2023: From then Getting intermittent giddiness episodes associated with numbness over left upper and lower limb.
When ever he is getting episodes he used to stay back in house .
3 weeks back 1 episode of syncopal attack while he was in shop in the afternoon.
Since 1week episodes are aggrevating 6days back 1 episode in house in the night.
Last episode 2days back 2episodes 1 in morning and 1 in the night associated with tingling sensation in ears before the episode and numbness over left upper and lower limbs relieved spontaneously after the attack .
He has h/o Frank blood in stools 1yr back
No H/o fever, vomitings,loose stools,burning micturition,cough,cold.
Daily routine-
He wakes up at 8am and does his activities and has his break fast (dosa/idly), and he carries his lunch box to shop and at 1pm(rice and curry) has his lunch and does his work and return back to house at 7pm and have his dinner at 9 pm(Rice with curry) and goes to bed at 10pm but he fall asleep after 40mins / 1hr. Due these episodes his work got affected.
Past history:
Not a k/c/o DM,HTN,CAD,CVA, EPILEPSY,TB,ASTHMA
Personal history:-
occupation : printing press
Diet -veg
Appetite -normal
Sleep - disturbed
Bowel and bladder movements:- Regular.
Addictions:- no
Patient is conscious,coherent, cooperative
Pallor present,
Icterus,cyanosis, clubbing, generalized lymphadenopathy, bilateral pedal edema absent
Vitals:-
BP-130/80 mmhg
PR-63bpm
RR:- 20 cpm
Spo2:- 99% @RA
GRBS:- 101gm/dl
Systemic examination:-
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
cranial nerves -
1-sense of smell - present
2-Direct and indirect light reflex present.
3. 3 and 4 and 6- no ptosis , squint , nystagmus.
5-corneal reflex present
7-fore head wrinkles ( frontalis)
Eye closure (orbicularis occuli)
Showing teeth (orbicularis oris)
Blowing ( buccinator)
Taste sensation over anterior 2/ 3 of tongue are normal.
8- hearing normal
9and 10- no deviation of ulva
11-shrugging of shoulders present
12-no tongue deviation.
Motor system
Right. Left
BULK
Upper limbs. N N
Lower limbs. N N
TONE
Upper limbs. N. N
Lower limbs. N N
POWER
Upper limbs. 5/5 5/5
Lower limbs 5/5 5/5
Superficial reflexes and deep reflexes are normal
Gait is normal
No involuntary movements
Meninges :
Neck stiffness - negative
Kerning sign -negative
Brudzinsk's sign - negative
Sensory system:
All sensations pain,touch, temperature, position, vibration are well appreciated.
Cerebellar signs:
Heel knee incoordinarion : no
Finger nose incoordinarion: no
Per abdomen:
Inspection:
Scaphoid shape of abdomen flat
Umbilicus: Inverted
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
Soft, non tender
No signs of organomegally
Percussion:
No fluid thrill, shifting dullness absent
Auscultation:
Bowel sounds heard
ENT referral
Ophthalmology referral
Neurology referral
Provisional diagnosis:
Giddiness under evaluation with anemia (MC/HC) secondary to IDA ? Nutritional?Blood loss with anal fissure with gastritis with generalised anxiety disorder with ?vestibular migraine with ? Syncope secondary to arrhythmias
Treatment:
1.plenty of oral fluids
2.Tab. orofer-X PO/OD
3.syp.Cremeffin plus 20ml PO/HS
4. Onit.Smuth L/A
5.Tab.Pantop 40mg PO/OD
6. Slitz bath
7. Tab dolo 650mg PO/SOS
8. Inj. Neomol 1gm IV/SOS ( if temperature >101F )
9.Tab Divalproate sodium 250mg PO/OD
10. Tab Clonazepam 0.25mg PO/OD/HS
