CNS case

PRELIMINARY DETAILS 

Name : Ramulamma

Age: 67

Sex: female

Occupation: Daily wage worker 15 yrs back

Address: motkur

Chief complaints

Giddiness since 1 week

History of present illness

Patient was apparently asymptomatic  1 week ago then she developed giddiness which was sudden onset

History of 3 episodes in 1 week

Each last for 1 or 2 mins then she recovers completely

In the last episode while drinking water she fell down and got injured and treated and came to hospital

No history of tinnitus, hearing loss, Vomiting, headach, ear pain, fever.

Her conditions relieved on sitting

Past history

Known case of seizures of GTCS variety

Known case of meningioma 12 yrs back

No history of DM , HTN , TB, Asthama

Personal history

Diet- mixed

Sleep- adequate

Appetite - decreased

Regular bowel and bladder moments

No addictions

Surgical history

Fracture in left limb

GENERAL EXAMINATION 

Patient was conscious and coherent

Cooperative

Built - moderate

Nourishment - moderately nourished

Pallor - absent

Cyanosis - absent

Clubbing - absent

Odema - absent

Icterus - absent

Lymphadenopathy - absent

Vitals

BP- 140/60mmhg

PR- 88 Per min

RR - 18 cycles per min

Temp- 96.8° F

GRBS - 115mg%

CNS EXAMINATION

conscious

Oriented to time, place,person

Speech - normal

Memory - intact

Cranical nerve examination

CN 1 - Smell- good

CN 2- confrontation test- normal

CN 3 4 6- extra ocular moments - normal

CN 5- 

Sensory - normal

Motor - normal

CN 7-

Sensory - normal

Motor - normal

CN 8- 

Rinnes - positive

Webers - not lateralized

CN 9 10- normal

CN 11-sternoceidomastoid - good

CN 12- tongue protrusion - normal

Motor system

Reflexes

Biceps jerk-++

Triceps jerk- -

Supinator jerk- -

Knee jerk-++

Ankle jerk--

Sensory system

Crude touch - normal

Pain- normal

Temp- normal

Cerebellar test

Finger nose in ordination - absent

CVS 

S1 S2 Sounds heard

Respiratory system

Normal vesicular sounds

Abdomen examination

No organomegaly

Provisional diagnosis

Giddiness under evaluation

Differential diagnosis

Vertigo

Dehydration

Sudden BP Drop

low blood sugar

Investigations








Treatment

Tab. Levipil 500mg ( Anti epileptic)

Tab. Vertin 8mg ( Betahistine - increases blood flow to inner ear)

Inj. Optineurin 1 amp in 100ml NS( Multi vitamin)

Potklor syrup (kcl)

Monitor vitals regularly 



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