44 year old female came to OPD with the complaint of giddiness and vomitings.

October 20, 2022

Name : k. Durga bhavani
Roll no : 35

This is an online e log book to discuss our patients de-identified health data shared after taking his / her / guardians singned informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evident based input . This E log also reflects my parent centred online learning portfolio and your valuable inputs on the comment box is welcome .

October 18 ,2022.

44 year old female came to OPD with the complaint of giddiness on the same day of morning at 5:00(5am) and  vomitings.

CHIEF COMPLAINTS:
Patients complaints of giddiness and vomiting

HISTORY OF PRESENT ILLNESS:
-No loss of consciousness
-patient had 2 episodes of vomitings in the morning of 16th October
-no bleed and mucus seen in vomiting
-no nausea, headache,and blurring of vision.
-no slurring of specch and no deviation of mouth

HISTORY OF PAST ILLNESS:
-k/c/o: hypertension since 4 years
-n/k/c/o: diabetes mellitus, tuberculosis, epilepsy,asthma, coronary artery disease
TREATMENT HISTORY: 
HTN since 4 years 
Treatment with.. Tab: telma 40mg
No cad, asthma, TB
No known history of taking antibiotics , Blood transfusion 

PERSONAL HISTORY:
-married
-occupation: daily labour.. stopped working four years ago
-non vegetarian
Bowel and bladder: regular
-micturition: normal
-no known allergies
-habbits: patient is having habit of consuming toddy occasionally
-no history of smoking, tobacco consuming,drugs,betel nuts and betel leaves

FAMILY HISTORY:

No other family member has similar complaints


PHYSICAL EXAMINATION
-no pallor
-no cyanosis
-no icterus
-no clubbing of fingers
-no bilateral pedal edema
-no lymphadenopathy
-no malnutrition
-no dehydration

Vitals:
Temp:97.4f
Respiratory rate:16c/min
Pulse rate:73/min
BP:170/90mmhg

SYSTEMIC EXAMINATION:
Cardiovascular system: no thrills,
no cardiac murmurs
Cardiac sounds- s1,s2 positive

Respiratory system: 
-no dyspnea
-no wheeze
-position of trachea-central
-breath sounds- vesicular
Abdomen:
Shape of abdomen-scalloped
Non tender
No palpable mass
Hernial orifice normal
Liver and spleen not palpable
No bowel sounds
Central nervous system:
Level of consciousness-conscious
Speech- normal
Signs of meningial irritation-a)neck stiffness
b) no kernigs sign 

Provisional diagnosis:
Bppv(benign paroxysmal positional vertigo)

Investigations:
MRI brain
Carotid Doppler
ECG

Treatment
telma 40 mg
Vertin 16mg
pregaba
Ultracet

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