A 80 Yr old male with giddiness and vomiting

A 80 year old  hypertensive male, resident of narketpally, labourer by occupation was brought to OPD on Thursday by his family with,

C/o :  1. Giddiness since 3 days 

          2. Vomitings since 3 days 

Hopi :

• Patient was apparently asymptomatic in the morning when he went to work 
• He started having vomitings after his lunch, 4 episodes, sudden in onset, which was not associated with nausea, contained food content, bilious, non projectile
• Vomitings are followed by giddiness and weakness, headache is present. 
• No fever, neck stiffness, abdominal pain and diarrhea.
• No loss of movements,  confusion, abnormality in speech 
• No incontinence of bladder or bowel movement 

Past history :

• Patient was diagnosed with hypertension around 2 years back on a routine check up
• He is taking regular medication 
• No H/ O diabetes mellitus, tuberculosis, asthma, epilepsy.
• No H / O any trauma
• No H / O surgeries

Personal history :

• Diet - mixed
• Apetite - normal
• Bowel and bladder - regular
• Consumes alcohol everyday - 90 ml
• Smokes a pack of beedis everyday 
• No h/o Allergies

General examination :

• Patient was examined after taking informed consent in a well lit room after he was comfortably seated 
• Patient was conscious, coherent, cooperative and well oriented to time and place. 
• Moderate built and moderate nourished 

No  pallor, Icterus, Cyanosis, clubbing, pedal edema, Lymphadenopathy.

There are multiple dilated tortuous veins on anterior part of right leg

Vitals :

• Pulse rate            :   80 bpm, normal rhythm 
• Blood pressure   :   120/90 mm of Hg 
• Respiratory rate :   14 cpm 
• Temperature.      :   afebrile

CNS examination : 

• Gcs - 15 /15 

Higher mental functions - 

• Patient is conscious, oriented to time and place 
• Memory is intact
•  Speech and language normal 

Cranial nerve examination -

• Nystagmus present
• Other cranial nerves intact 

Motor examination : 

               

                                      Right.                Left 

Bulk                             normal               normal 

Tone  - upper limb    normal               normal 

             Lower limb    normal               normal 

Power - upper limb    5 / 5                      5/5 

               Lower limb   5 / 5                      5/5     

Reflexes - knee jerk   :  absent                absent 

                   Ankle jerk :  absent.              absent 

                   Biceps        :  absent                absent 

                   Plantar      :  absent                 absent 

Sensory examination  

Normal 

Cerebellar examination - 

   

Finger nose test      :   coordination present 

Knee heel test          :  coordination present 

Dysdiadokokinesia : absent 

Nystagmus present 

Abdominal examination : 

• Soft, non tender 
• No organomegaly 

CVS examination : 

• S1 and S2 heard 
• No murmurs. 

Respiratory examination : 

• Bae present 
• Normal vesicular breath sounds 

Ent examination : 

• Normal 

Investigations : 

Hemogram 

Aptt

CUE 

Prothrombin time 

Ecg 

MRI brain 

 

Diagnosis : 

Giddiness under evaluation 

Treatment : 

1) TAB. PROMETHAZINE 25 mg PO/TID
2) INJ. VERTIN 16mg PO/TID
3) TAB. AMLONG 5 mg PO/OD (8 am)
4) TAB. PANTOP 40 mg PO/OD
5) TAB. AUGMENTIN 625 mg PO/BD
6) TAB. THIAMINE 100 mg PO/BD
7) TAB. NAPROXEN 250 mg PO/BD
8) Vitals monitoring - 4th hrly

9)Grbs fourth hourly