80Y/ M CAME WITH C/O FEVER SINCE 3 DAYS C/O GIDDINESS SINCE 3 DAYS
C/O FEVER SINCE 3 DAYS
C/O GIDDINESS SINCE 3 DAYS
HOPI:
PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK THEN DEVELOPED FEVER LOWGRADE, CONTINUOUS, NOT A/W CHILLS AND RIGORS
C/O GIDDINESS INSIDIOUS ONSET ASSOCIATED WITH CHANGES IN POSITION , MORE IN SLEEPING POSTURE AND BENDING FORWARD
A/W NAUSEA, VOMITING 1 EPISODE YESTERDAY NIGHT
H/O COUGH WITH SPUTUM, MUCOID CONSISTENCY, NON FOUL SMELLING
H/O SOB
NO H/O CHEST PAIN , ABDOMINAL PAIN
NO H/O PEDAL EDEMA
NO H/O BLACK OUTS, TRAUMA
NO H/O EAR PAIN, PUS DISCHARGE FROM EAR
PAST HISTORY:
K/C/O HYPERTENSION SINCE 5 YEARS ON TAB AMLO 5 MG PO OD
N/K/C/O DM, CVA, CAD, EPILEPSY, ASTHMA, THYROID DISORDER
PERSONAL HISTORY:
DIET:MIXED
SLEEP:ADEQUATE
BOWEL AND BLADDER:REGULAR
ADDICTIONS:NO
APPETITE:NORMAL
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.
NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.
VITALS:
TEMPERATURE:98
BP:100/70 MM HG
PR:82 BPM
RR:18 CPM
SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD NO MURMURS.
RS:BAE +,NO MURMURS
PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY
CNS: HIGHER MENTAL FUNCTION PRESENT,
CEREBELLAR FUNCTION TEST
FINGER NOSE COORDINATION PRESENT
FINGER FINGER COORDINATION PRESENT
KNEE HEEL TEST NEGATIVE
DYSDIADOKINESIA ABSENT
ROMBERG TEST NEGATIVE
NYSTAGMUS - VERTICAL IN SUPINE POSITION FOR 10 SEC
ENT REFERRAL DONE ON 27/1/24 I/V/O NYSTAGMAS
UNABLE TO PERFORM DIX HALPIK MANEUVER AND HEAD IMPULSE TEST I/V/O SEVERE NECK PAIN .
KINDLY CONTINUE SAME MEDICATION AS ADVISED BY PRIMARY PHYSICIAN
OPTHAL REFERRAL DONE ON 27/1/24 I/V/O REFRACTORY ERROR IN B/L EYES
VA : RE-6/60. 6/24 ; LE -6/60. 6/36
ADVICE: USE SPECTACLES AND REVIEW TO OPTHALMOLOGY OPD AFTER 3 MONTHS
INVESTIGATIONS:
HBsAg-RAPID 24-01-2024 05:02:PM Negative
Anti HCV Antibodies - RAPID 24-01-2024 05:02:PM Non Reactive
POST LUNCH BLOOD SUGAR 24-01-2024 05:02:PM 126 mg/dl 140-0 mg/dl
RFT 24-01-2024 05:02:PM
UREA 18 mg/dl 50-17 mg/dl
CREATININE 1.3 mg/dl 1.3-0.8 mg/dl
URIC ACID 4.0 mg/dl 7.2-3.5 mg/dl
CALCIUM 10.1 mg/dl 10.2-8.6 mg/dl
PHOSPHOROUS 3.9 mg/dl 4.5-2.5 mg/dl
SODIUM 135 mEq/L 145-136 mEq/L
POTASSIUM 4.4 mEq/L 5.1-3.5 mEq/L
CHLORIDE 102 mEq/L 98-107 mEq/L
LIVER FUNCTION TEST (LFT) 24-01-2024 05:02:PM
Total Bilurubin 0.63 mg/dl 1-0 mg/dl
Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 12 IU/L 35-0 IU/L
SGPT(ALT) 10 IU/L 45-0 IU/L
ALKALINE PHOSPHATE 136 IU/L 119-56 IU/L
TOTAL PROTEINS 7.2 gm/dl 8.3-6.4 gm/dl
ALBUMIN 3.8 gm/dl 4.6-3.2 gm/dl
A/G RATIO 1.13
COMPLETE URINE EXAMINATION (CUE) 24-01-2024 05:02:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN Nil
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 1-2
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
HAEMOGLOBIN
13.7
gm/dl
13.0 - 17.0
Colorimetric
TOTAL COUNT
4,000
cells/cumm
4000 - 10000
Impedence
NEUTROPHILS
57
%
40 - 80
Light Microscopy
LYMPHOCYTES
30
%
20 - 40
Light Microscopy
EOSINOPHILS
03
%
01 - 06
Light Microscopy
MONOCYTES
10
%
02 - 10
Light Microscopy
BASOPHILS
00
%
0 - 2
Light Microscopy
PCV
# 39.5
vol %
40 - 50
Calculation
M C V
88.8
fl
83 - 101
Calculation
M C H
30.8
pg
27 - 32
Calculation
M C H C
# 34.7
%
31.5 - 34.5
Calculation
RDW-CV
13.1
%
11.6 - 14.0
Histogram
RDW-SD
43.5
fl
39.0-46.0
Histogram
RBC COUNT
# 4.45
millions/cumm
4.5 - 5.5
Impedence
PLATELET COUNT
2.62
lakhs/cu.mm
1.5-4.1
Impedence
SMEAR
RBC
Normocytic normochromic
Light Microscopy
WBC
With in normal limits
Light Microscopy
PLATELETS
Adequate in number and distribution
Light Microscopy
HEMOPARASITES
No hemoparasites seen
Light Microscopy
IMPRESSION
Normocytic normochromic blood
picture
DIAGNOSIS:
BENING PAROXYSMAL POSITIONAL VERTIGO
BILATERAL SENSORY NEURAL HEARING LOSS
HYPERTENSION
TREATMENT:
TAB SPINFREE BD 1--0--1 FOR 1 WEEK
TAB PAN MG PO OD
TAB DYTOR PLUS 10/50 PO OD 9 AM--0--0 FOR 3 DAYS
TAB ULTRACET BD 1--0--1` FOR 5 DAYS
TAB SHELCAL CT PO OD 0--1--0 FOR 15 DAYS
CERVICAL COLLAR APPLICATION
NECK STRENGTHING EXERCISES
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