60 YEAR OLD MALE WITH COMPLAINTS OF GIDDINESS

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"

This is case of 60 year old male came to casualty with chief complaints :

Patient c/o giddiness since 6days

C/o headache since 6days

Hopi:

Patient was apparently sympatomatic 10 years back then he had stomach ache for which he was referred to our hospital. Then he was diagnosed with intestinal perforation and he was operated and discharged after 6 days.

 4yrs back he fell in drainage pit and got ankle fracture. And he got nail plate operated and removed after 1 month

6 days back pt has giddiness on walking and vomiting 5-6episodes non projectile, non bilious, food as content.

Headache for which he was taken to near by govt hospital amd treated symptomatically for 5days amd referred to higher centre.

Past history 

Not k/c/o DM,HTN,epilepsy, asthma, CAD

General examination

Patient is conscious, coherent,cooperative 

 

No PICKLE

Vitals:

Temperature: 98 F

Bp 130/80 mm hg

PR 82 bpm

RR. 16cpm

GRBS 108mg/dl

CVS Examination :

Heart sounds: s1 s2 heard

No murmurs

Respiratory examination :

NVBS

Per abdomen:

Non tender, soft

CNS Examination:

Level of consciousness: conscious 

Speech: normal

No signs of meningeal irritation

CRANIAL NERVE examination :

C1  normal 

C2 normal 

C3  vision decreased in left eye 

C4 normal 

C5 normal 

C6 normal 

C7 normal 

 C8 normal 

 C9  normal 

 C10  normal 

C11   normal 

C12  normal 

MOTOR EXAMINATION:

                            UL                     LL

1.Bulk

Rt               normal/no wasting   normal/no wasting

Lt                 normal                  normal 

2.Tone 

Rt             normal                     normal 

Lt             normal                   normal 

3.power 

Rt            5/5                       5/5

Lt           5/5                      5/5 

4.reflexes   biceps    triceps  supinator ankle

    Rt           ++              ++         ++             ++      

   Lt         ++              ++           ++            ++        

Knee jerk 

Rt    +++

Lt    +++

Plantar 

Rt     flexion 

Lt      flexion 

Sensory examination:

fine touch  and Crude touch    normal 

Pain     normal 

Temperature   normal 

Propriception  normal 

Vibration   normal 

Cerebellar function:

Finger nose test    incordination 

Finger finger test     incordination 

Nystagmus   no 

Knee heel      impaired 

Dysdiadochokinesia impaired 

Rombergs    postive swaying to right side

Gait

Knee jerk

Provisional diagnosis :

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

INVESTIGATIONS :

MRI BRAIN :

Ecg :

on 22 /5/22 :

Rbs -121 mg/dl

Blood urea :22 mg/do

S.elctrolytes :

Na +  :139 meq/ml 

K+  :4.5  meq/ml

Cl-  :98 meq/ml

Hemogram:

Hb :18.1 gm /dl 

TLC: 10000 cells /cumm

Plt : 3.38 lks

N/l/E  :60 /26/5

LFT :

Total bilirubin:1.48 mg /dl 

Direct bilirubin:0.52 mg/do

AST  26  IU

ALT   27 IU

ALP 124  IU 

Total protein  7.1 gm /dl

Albumin  4 gm /dl

Treatment :

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

5.TAB PROMETHAZINE 25MG PO BD

SOAP NOTES :

DAY 1 

AMC BED NO 6 

S:

Complaints of GIDDINESS 

Rombergs postive swaying to right 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :120/80 mmhg 

PR :82 BPM

RR:17CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

AMC BED NO 6 

Day2 

S:

GIDDINESS SUBSIDED 

NO FRESH COMPLAINTS 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :120/80 mmhg 

PR :86 BPM

RR:16CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

AMC BED NO 6 

Day 3 

S:

No new complaints 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :120/80 mmhg 

PR :84 BPM

RR:17CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

AMC BED NO 6 

Day 4

S:

Complaints of vomitings 4episodes 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :110/80 mmhg 

PR :87 BPM

RR:17CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

5 TAB PROMETHAZINE 25MG PO BD 

AMC BED NO 6 

Day 5

S:

Complaints of vomitings and loose stools 3 episodes 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :120/90 mmhg 

PR :92 BPM

RR:16 CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

5.TAB PROMETHAZINE 25MG PO BD 

DAY 6

AMC BED NO 6 

S:

vomitings and loose stools subsided 

No fresh complaints 

O: 

On examination 

Patient Is  C/C/C

No PICKLE 

BP :110/80 mmhg 

PR :88 BPM

RR:16CPM

SPO2 :98 ON RA 

A:

ACUTE ISCHEMIC STROKE ( cerebellar infarct)

? PICA 

P:

1.TAB ATORVAS 80 mg PO HS 

2.TAB PAN 40 MG PO OD

3. TAB VERTIN 8 mg TID

4.TAB STROCIT   PLUS 800 mg/500mg  PO BD

5.TAB PROMETHAZINE 25MG PO BD