A 73 year old male with giddiness and decreased hearing
CBBLE UDHC SIMILAR CASES
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
73/M ; SS ward
A 73 year old male came to the hospital with c/o giddiness since 7-8 months
Neck stiffness since 7 months
Patient was apparently asymptomatic one year back when he went to a local hospital with complaints of heart burn and right sided chest pain where he got diagnosed with hypertension and was given RAZO D for heart burn and was started on telma 40.
Since 8 months patient started complaining of giddiness while walking and while squatting in washroom or while urinating and subsides only after sitting, for which patient was put on Tab. Stemetil but did not subside
Associated with neck stiffness and mild diffuse headache.
Patient went to a local hospital with similar complaints where they ran some basic investigations on him . His ecg there showed ST-T changes in lead 3 and avF and Right bundle branch block .and his chest x-ray showed COPD.
Echo showed mild LVH .Since then he was put on ecospirin 75
X ray cspine showed spondylotic changes
Patient complaints of decreased urine flow since 8 months (?enlarged prostate)and patient was taking TAB FLODART PLUS(Tamsulosin) at bed time for above complaints.
Grade 3 sob since one year and he was using FORACORT inhaler(budesonide and formoterol) but patient was not compliant to the medication.
Patient complaints of decreased hearing in right ear since one month (he recognised it while talking on the phone when he could hear better in his left ear)
Past history:- Patient is a k/c/o HTN since one year and is on telma 40
Past surgical history:-
Gall stones removal 7 years back
Operated for piles 6 years back
Addictions:-
Patient used to consume alcohol and was a smoker when he was young but stopped since 40 years , but still eats pan on a regular basis
General examination:-
Patient is conscious coherent cooperative oriented to time place and person.
No signs of pallor icterus cyanosis lymphadenopathy pedal edema
Vitals :-
BP:- supine- 110/70mmhg standing (after 3 mins) 110/70 mmhg
PR:- 85 bpm
RR: -18 cpm
Temp- afebrile
S/E
CVS S1,S2 heard, no murmurs
RS :- BAE present but decreased
P/A soft non tender, obese abdomen.
CNS :- R. L
Tone. N. N
Power. N. N
Reflexes
Biceps 2+. 2+
Triceps. 2+. 2+
Supinator 2+. 2+
Knee 2+. 2+
Ankle. 2+. 2+
Plantar - Flexor
Finger nose coordination:- present, no past pointing
Romberg's - negative
Gait- normal
https://youtube.com/shorts/cgoK8kJc1vs?feature=share
Investigations
RBS :- 87 mg/dl
Blood urea- 31 mg/dl
Hb- 9.9 g/dl
TLC- 7000 cells/cumm
RBC in smear - microcytic hypochromic
LFT:-
TB:- 1.14 mg/dl
DB:- 0.42 mg/dl
ALP- 212 IU/L
TP:- 6.3 g/dl
Serum creatinine:- 1.2 mg/dl
2D ECHO
Ecg:-
ENT opinion
Adviced for video nystagmography
Examination not suggestive of peripheral vertigo
1)TAB ECOSPIRIN 75mg PO OD
2)TAB. TELMA 40 PO OD
3)TAB RABEPRAZOLE 30mg PO OD
6/3/22
Day 2 SOAP NOTES:-
73/M; SS WARD
S:- Complaints of giddiness while walking
O:-
Patient is conscious, coherent, cooperative
No signs of pallor, icterus, cyanosis, lymphadenopathy, pedal edema
BP- 90/60 mmhg
PR- 70 bpm
RR- 20 cpm
CVS- S1,S2 heard, no murmurs, no thrills, no tender points.
Respiratory system:- BAE + , Nvbs heard
P/A :- soft, non tender,obese abdomen, no orgamomegaly
CNS :- R. L
Tone. N. N
Power. N. N
Reflexes
Biceps 2+. 2+
Triceps. 2+. 2+
Supinator 2+. 2+
Knee 2+. 2+
Ankle. 2+. 2+
Plantar - Flexor
Finger nose coordination:- present, no past pointing
Romberg's - negative
FBS:- 100mg/dl
PLBS:- 136 mg/dl
HbA1c - 6.5 %
A:- Giddiness under evaluation with HFpEF
P:
1)TAB ECOSPIRIN 75mg PO OD
2)TAB. TELMA 40 PO OD
3)TAB RABEPRAZOLE 30mg PO OD
7/3/22
Day 3:-
Pure tone audiometry done
Acoustic dip at 4000hz and absence of air bone gap indicates ?NIHL(Noise induced hearing loss) in right ear and mild SNHL in left ear.
USG Abdomen and pelvis done:-
Impression- Grade 1 fatty liver
Comments
Post a Comment