A 40 year old female with giddiness

A 40 year old female, resident of Bachupalli, whose occupation is to water plants in a nursery, came with the chief complaints of:

1. Giddiness since 1 day

• The patient was apparently asymptomatic 6 years ago when she noticed that she had lost some weight. Additionally, she had 2-3 episodes of nausea within a week and hence consulted a doctor. Upon investigation, she was found to have gallstones. The doctor advised against surgery at that time, and hence, she was given medication (what medication?). She continued to take these tablets for 2 years.

• 4 years ago, the patient suddenly developed right sided loin pain, which was radiating towards the back, persistent in nature, and not associated with fever, nausea, burning micturition, hematuria or pedal edema. The pain lasted for 10 days after which she consulted a doctor. Initially, she was given medication for a week for the same and asked to follow up after one week. However, her symptoms did not subside. Hence, one week later, she went for a follow-up, where she was diagnosed with a kidney infection (reports?), and a Right sided nephrectomy was done.

• Since one of her kidneys were removed, the doctor also advised against continuing her gallstone medication as it would affect her kidney. Hence, she stopped taking it 4 years ago.

• 10 months ago, the patient developed SOB, which was sudden in onset, grade II NYHA, non-progressive, and intermittent, occuring about 2-3 times per week. On consultation, the doctor said that the cause was most likely gallstones, but advised against medication as she had only one kidney. The SOB subsided on its own 1 month back. It was not associated with orthopnoea, PND, chest pain or palpitations. 

• 1month ago, the patient developed facial puffiness, for which she consulted a doctor. On performing investigations, she was diagnosed with hypothyroidism. She has been on thyroxine medication everyday since then. No other Symptoms or signs of hypothyroidism were present. 

• Yesterday morning, she felt dizzy as soon as she woke up and had to sit down. The dizziness increased on standing and sitting, and decreased mildly on laying down. She described it as "her surroundings were moving around her". She also felt weak. Due to the dizziness, she was not feeling like eating anything and hence, only ate one idli the whole day.

• It was not associated with headache, blurring of vision, nausea.

In the morning, they went to one doctor who said that it was most likely hypoglycemia. However, even on IV administration, get condition did not improve and she was hence taken to another hospital. The hospital felt that she should be referred for further investigation and she was hence brought to our hospital. 

PAST HISTORY

No similar complaints in the past

No h/o DM, HTN, asthma

PERSONAL HISTORY:-

Diet: Non-Vegetarian

Appetite: Normal

Sleep: Adequate

Bowel & bladder: Regular

No addictions/allergies

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

Pt is conscious, coherent, cooperative

Well oriented to time, person, place

Moderately built, well nourished

No pallor/icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

VITALS:

Temp: Afebrile

PR: 91bpm

RR: 17cpm

BP: 130/90mmHg

Spo2: 98%@RA

GRBS: 147mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, No murmurs

RS: BAE+, NVBS, no adventitious breath sounds

P/A: soft, non tender 

EVALUATION FOR GIDDINESS:

1. Autonomic function: Normal

2. CNS examination: 

1) HMF - INTACT 

2)MOTOR SYSTEM : 

                    Right Left

Bulk: 

Inspection.   N N

Palpation.     N N

Tone: R/L

UL.  N N

LL.   N N

Upper Limb:

Shoulder:

Flexion. 5/5 5/5

Extension. 5/5. 5/5 

Abduction: 5/5. 5/5 

Adduction: 5/5. 5/5 

Elbow: 

Flexion (biceps) 5/5. 5/5 

Extension (triceps) 5/5. 5/5

Lower Limb:

Gluteus max. 5/5 5/5

Adductor femoris. 5/5 5/5

Hamstrings. 5/5 5/5

Quadriceps. 5/5 5/5

Tibialis ant. 5/5 5/5

Tibialis post. 5/5 5/5

Deep tendon reflexes:

Biceps: +2 +2

Triceps: +2 +2

Supinator:. +2 +2

Knee: +2 +2

Ankle: +2 +2

Plantar: flexor

Sensory:

Crude touch. + +

Pain. + +

Temp. + +

Fine touch-- present

Vibration. + +

Position. + +

CRANIAL NERVES : Intact

Cerebellar signs : Normal

https://youtu.be/YE28HdlPuAU

3. Local causes: no hearing loss, discharge from the ears or pain present

On performing Dix-Hallpike maneuvre, the patient noted that she felt a slight increase in dizziness when performed on the left side. 

INVESTIGATIONS: 

General investigations:

On day of admission:

MRI BRAIN: NAD

ECG:

PROVISIONAL DIAGNOSIS:

Giddiness under evaluation d/t BPPV? VESTIBULAR MIGRAINE?

TREATMENT PLAN: 

-INJ. PROMETHAZINE 25MG IV/TID

-INJ. OPTINEURON 1AMP IN 100ML NS/IV/OD

-INJ. PAN40MG IV/OD

-TAB VERTIN 32MG PO/BD

-VITALS MONITORING

Day 2:

S:

Patient feels better. No generalized weakness.

Patient complains of left sided dragging type of headache.

O:

O/E

Pt was C/C/C

PR: 86 bpm

BP: 110/70 mm of Hg

RR: 16 cpm

SpO2: 98% on RA

CVS: S1 , S2 HEARD

P/A : NON TENDER, SOFT

RS: BAE+

Interpretation: Normal B/L HEARING

Normal X-RAY NECK

A: GIDDINESS ON EVALUATION SECONDARY TO BPPV? VESTIBULAR MIGRAINE?

P:

TREATMENT PLAN: 

-INJ. OPTINEURON 1AMP IN 100ML NS/IV/OD

-INJ. PAN40MG IV/OD

-TAB VERTIN 32MG PO/BD

-VITALS MONITORING

Day 3:

S:

Patient feels better. No generalized weakness.

Patient complains of left sided dragging type of headache.

O:

O/E

Pt was C/C/C

PR: 86 bpm

BP: 110/70 mm of Hg

RR: 16 cpm

SpO2: 98% on RA

CVS: S1 , S2 HEARD

P/A : NON TENDER, SOFT

RS: BAE+

A: GIDDINESS ON EVALUATION SECONDARY TO BPPV? VESTIBULAR MIGRAINE?

P:

TREATMENT PLAN: 

-INJ. PAN40MG IV/OD

-TAB VERTIN 32MG PO/BD

-VITALS MONITORING