80 yrs male with complaints of vomitings 2 episodes since morning and giddiness since morning

80 years male who is a farmer by occupation came to casuality with chief complaints of vomiting 2 episodes since morning and giddiness since morning.

HOPI:

- Patient was apparently asymptomatic 4 years back and on road in village health checkup he was diagnosed to have hypertension and he was put on tablet atenolol 50 mg since 4 years.

- Today morning, he woke up and ate food and after 2 1/2 hours, he went to his work in field, while working in the field he had sudden onset of giddiness followed by vomitings-2 episodes - bilious,non projectile type not associated with pain abdomen, fever, loose stools.

- Vomitings followed by giddiness (self reeling type) since morning - sudden onset aggravated with movements or sitting up, swaying while walking present, associated with headache holocranial type, associated with nausea and vomitings.

- No history of loss of consciousness, seizures, diplopia, blackouts, chest pain, constipation, sweating and palpitations, earache, aural fullness or discharge, tinnitus 

- No complaints of weakness, tingling or numbness of limbs, difficulty in chewing, swallowing, deviation of mouth

- No bowel and bladder incontinence.

PAST HISTORY:

- K/C/O Hypertension since 4 years - on treatment TAB. ATENOLOL 50 mg

- Not a K/C/O diabetes mellitus/TB/Epilepsy/BA/CAD/CVA

PERSONAL HISTORY:

Diet- mixed

Sleep- adequate

Appetite- decreased since 10 days

Bowel and bladder movements- regular

No known allergies

- ALCOHOLIC SINCE 40 YEARS- 3 times/week 90 ml

- SMOKER SINCE 40 YEARS- 1 packet/day

FAMILY HISTORY: Not Significant

GENERAL EXAMINATION:

-Patient is Conscious, coherent and cooperative.

-No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.

VITALS:

Temperature - Afebrile

PR- 68 bpm

RR- 14 cpm

BP- 120/70 mmHg

SpO2- 99% at RA

GRBS- 132 mg/dL

SYSTEMIC EXAMINATION:

CVS- S1S2 heard, no murmurs

RS- BAE+, NVBS+

P/A- Soft, Non-tender

CNS:

Patient is oriented to time,place,person

Memory : recent, remote intact

Speech: Normal

Cranial nerves: Intact

Motor system: 

Power-5/5 in both upper and lower limbs

Tone- Normal in bilateral upper and lower limbs

Sensory system: crude ,pain, temperature, fine touch, joint position, proprioception are normal in all dermatomes

GCS: 15/15

GAIT:

Reflexes :

Biceps, Triceps, Supinator, Knee and ankle reflexes were absent

Plantars: mute

Cerebellum:

Finger nose coordination +

Knee heel coordination +

No dysdidokinesia.

Nystagmus+ in both horizontal and vertical gaze.

INVESTIGATIONS:

Hemogram on 6/01/2022:

Hemogram on 7/01/2022:

CUE:

PT,APTT,INR:

ECG on 7/01/2022:

ECG on 8/01/2022:

USG ABDOMEN:

MRI BRAIN:

ASSESSMENT:

Giddiness under evaluation secondary to ?PCA Stroke with Hypertension.

ENT REFERRAL:

PLAN OF CARE:

1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID

2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD

3) INJ. PANTOP 40 mg IV/BD

4) INJ. ZOFER 4 mg IV/TID

5) TAB. PROMETHAZINE 25 mg PO/TID

SOAP NOTES:

7/01/2022:

Day 2

SUBJECTIVE: 

No episodes of vomitings

Giddiness reduced than yesterday,but still present

Head ache and nausea

OBJECTIVE:

Bp:120/70mmhg

PR 83bpm

RR: 16

Spo2 :98% at room air

Cvs:s1s2+

Rs: NVBS

Nystagmus +

ASSESSMENT:

PCA stroke with hypertension

Giddiness under evaluation

PLAN OF CARE:

ENT Opinion to be taken

1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID

2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD

3) INJ. PANTOP 40 mg IV/BD

4) INJ. ZOFER 4 mg IV/TID

5) TAB. PROMETHAZINE 25 mg PO/TID

8/01/2022:

Day 3

SUBJECTIVE: 

No episodes of vomitings

Giddiness reduced than yesterday, but still present

Head ache and nausea +

OBJECTIVE: 

Bp:150/90mmhg

PR 83bpm

RR: 16

Spo2 :98% at room air

Cvs:s1s2+

Rs: NVBS

Nystagmus +

ASSESSMENT:

Giddiness under evaluation with PCA Stroke

  

PLAN OF CARE:

1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID

2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD

3) INJ. PANTOP 40 mg IV/BD

4) INJ. ZOFER 4 mg IV/TID

5) TAB. PROMETHAZINE 25 mg PO/TID

Day 4

ICU Bed-2 case shifted to Ward:

S: Headache + , giddiness +

No nausea, No episodes of vomitings

O: 

Pt. is C/C/C

Afebrile

Bp: 120/70 mmHg

PR: 80 bpm

RR: 14 cpm

GRBS-: 109 mg/dL

Spo2 :98% at room air

CVS: S1S2 +

RS: BAE+ , NVBS+

P/A: Soft, Non-tender

Nystagmus +

B/L Plantars: Flexion

A :

PCA Stroke with Hypertension with Alcohol and Tobacco Dependence Syndrome (Chronic Smoker and alcoholic )

P : 

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

10) GRBS 12th hrly