40 year old female with GIDDINESS UNDER EVALUATION SECONDARY TO ? BPPV,? VESTIBULAR MIGRANE,?CERVICOGENIC VERTIGO

CBBLE  UDHC SIMILAR CASE STUDY

C/O GIDDINES SINCE  MORNING

HOPI-PT WAS APPARENTLY ASSYMPTOMATIC  TILL MORNING THEN SHE HAD GIDDINESS WHILE GETTING UP FROM THE BED.
GIDDINESS WAS SELF RELIEVING

SHE WAS  FEELING LIKE FALLING TO LEFT SIDE WHILE WALKING.
 
PT HAS COMPLAINTS OF HEADACHE(UNILATERAL-LEFT SIDE)
AND PHOTOPHOBIO PRESENT.

 GIDDINESS CONTINOUS,RELIEVING WITH SUPINE POSITION

AGGREVATED WITH CHANGE IN POSTURE

PT HAD NO AURAL FULLNESS

NO H/O DIZZINESS ON EXPOSURE TO 
SOUND.

NO H/O DECREASED HEARING,RINGING SENSATION


NO WEAKNESS,

NO NYSTAGMUS

NOT ASSOCIATED WITH VOMITINGS



NO H/O ANY TRAUMA /FALL.

PAST H/O-NO H/O SIMILAR COMPLAINTS IN THE PAST

NO H/O DM,HTN,EPILEPSY, CVD

FAMILY H/O-NO SIGNIFICANT FAMILY H/O

PERSONAL H/O-PT IS MODERATELY BUILT AND MODERATELY NOURISHED

BOWEL AND BLADDER MOVEMENTS-REGULAR

NO ADDICTIONS

GENERAL EXAMINATION-PT CONSCIOUS,COHERENT AND COOPERATIVE

VITALS-

BP-110/70 mm HG

PR-78

TEMP-AFEBRILE

RR-16

SYSTEMIC EXAMINATION-

CVS-S1,S2 HEARD,NO MURMURS

RS-BAE+,NVBS HEARD

P/A-SOFT,NONTENDER

CNS-NAD

INVESTIGATIONS-

1.HEMOGRAM-
Hb-11.9 GM/dl
TC-6,900
RBC-3.99 millions/cumm
PLT-2.68 lakh/cumm

2.LFT-
TB-0.65
DB-0.20
ALP-133
ALBUMIN-2.8
SGOT-19
SGPT-0.7
A/G-0.80
TP-6.4

3.RFT-
UREA-25
CREATININE-0.8
URIC ACID-5.2
SODIUM-142
POTASSIUM-4.1
CHLORIDE-105

4.serology-negative

5.MRI BRAIN
6.ECG




TREATMENT-
1.INJ OPTINEURON 1amp in 100 ml NS/IV/OD
2.INJ PAN 40 MG/IV/OD
3.TAB VERTIN 16 mg/po/bd
4.VITALS MONITORING

DIAGNOSIS-
GIDDINESS UNDER EVALUATION SECONDARY TO ? BPPV,? VESTIBULAR MIGRANE,?CERVICOGENIC VERTIGO

ENT REFERRAL-

SOAP NOTES-
DAY-1

23/02/2022
40Years/female
S:
C/O Giddiness
O:
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:82bpm
BP:110/70 mm of hg
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER.
A:
Giddiness under evaluation secondary to BPPV
P:
1.Inj.Optineuron 1amp in 100ml/NS/IV/OD
2.Inj.Pan 40mg/IV/OD
3.INJ promethazine 25 mg Iv/tid
4.TAB VERTIN 16 mg po/bd
5.Bp/PR/Temp charting


DAY-2

Ward update
24/02/2022
40Years/female
S:
C/O Giddiness
O:
O/E:No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:Afebrile
PR:86bpm
BP:110/70 mm of hg
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER.
A:
Giddiness under evaluation secondary to ?BPPV?vest
P:
1.Inj.Optineuron 1amp in 100ml/NS/IV/OD
2.Inj.Pan 40mg/IV/OD
3.Bp/PR/Temp charting
4.TAB VERTIN 16 mg po/bd

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