PERIPHERAL VERTIGO

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Venkata Meghana Badam
3rd sem, roll no -146

Under the guidance of Dr. Manasa( intern) 

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

CASE SCENARIO:
A 18 yr old female came to causality which chief complaints of giddiness

HISTORY OF PRESENT ILLNESS:
The patient was asymptomatic till 4 pm today . She had onset of giddiness not associated with nausea blackouts, blurring of vision, sweating, loss of consciousness, involuntary movements, headache, palpitations and chest pain. 
Dizziness since 2 pm today not reliving with rest and food intake. 
No history of vomitings, loose stools and loss of appetite. 
Last menstruation 28/06/2021.

HISTORY OF PAST ILLNESS:
N/K/C/O HTN, DM2, TB, epilepsy, CVA, CAD. 

TREATMENT HISTORY :
Not significant

PERSONAL HISTORY :
Married 
Housewife
Appetite normal
Non vegetarian
Bowels regular
Micturition normal
No known allergies, addiction

FAMILY HISTORY :
NAD 

MENSTRUAL HISTORY:
Age of menarche - 13
Menstrual cycle - 28/06/21, 3-4 days cycle
Lmp - 28/06/21
Gynaecological problem - no

OBSTETRIC HISTORY:
Age of marriage - 18
Gravida - 0 
Para - 0

GENERAL EXAMINATION :
No pallor
No icterus
No cyanosis
No clubbing
No Lymphdenopathy
No malnutrition
No dehydration
VITALS :
Temp afebrile
Pulse 90 bpm rate
Respiratory rate 12 cpm
Bp 110/70 mm Hgleft, 100/70mm Hg right 
SPO2 99 ℅
GRBS 130 mg%

SYSTEMATIC EXAMINATION :
CVS -
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
Respiratory -
No dyspnea
No wheezing
Position of trachea central
Breath sounds vesicular 
Abdomen -
Shape Schapoid 
No tenderness
Palpable mass
Free fluid 
No Bruits
No bowel sounds 
Hernial orifice normal 
Liver not palpable 
Spleen not palpable
Genitals normal
CNS -
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit

DIAGNOSIS :
Giddiness / peripheral vertigo 

TREATMENT:
Inj. Optineuron 1 Amp in 100ml Ns Iv/stat
Inj. Pantop 40mg Iv/stat
Inj. Zofer 4mg Iv/sos

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