GIDDINESS UNDER EVALUATION SECONDARY TO A) HTN ? B)AUTONOMIC NEUROPATHY ? WITH DENOVO HTN WITH HYPERTERNSIVE RETINOPATHY WITH K/C/O DM-2 WITH DIABETIC NEUROPATHY .
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A 45yr old male patient resident of pedhakaparthy came to the casualty with
c/o giddiness since 2days , non rotational , duration-10min, aggravated on standing , relieved by supine.
HOPI -
Patient was apparently asymptomatic 2days back and had an episode of giddiness , where he went to the local RMP and was found to have increased BP and patient had given TAB .AMLONG , TAB .ATENOLOL and didn't have any episode of giddiness .
From yesterday morning patient again started c/o giddiness and from yesterday afternoon c/o vomitings - non bilious , 2-3 episodes , non projectile and came to our hospital for further evaluation .
H/o alcohol intake 2days back .
Past History - k/c/o DM since 10yrs .
Not a k/c/o HTN , TB, Asthma , CAD, CVD
Personal history -
Diet - mixed
Appetite - normal
Bowel & bladder movements - regular
Addictions - occasional alchol intake
Family history - not significant
On Examination
patient is c/c/c
No pallor , icterus , cyanosis , clubbing lymphadenopathy , edema
Vitals -
Temp - Afebrile
PR - 90bpm
BP - 150/90 mmHg
RR -14cpm
GRBS - 98%@RA
SpO2- 98%
Systemic examination -
CVS - S1 S2 +VE
RS -BAE +VE , NVBS +VE
P/A - soft , non tender , BS +ve
CNS - NAD
Provisional diagnosis -
Giddiness under evaluation secondary to
a) HTN ? b)Autonomic neuropathy ? with denovo HTN with diabetes
Treatment -
INJ. ZOFER 4MG /IV/TID
INJ.PAN 40MG /IV/OD
T. AMLONG -5MG/PO/OD
T.GLUCORYL M2 PO /OD
T.ZINCOVIT PO/OD
Day1
AMC
Bed no 2
S-
c/o giddiness + , no c/o vomitings
O-
patient is c/c/c
Temp - Afebrile
PR - 90bpm
BP - 150/90 mmHg
RR -14cpm
GRBS -152 mg/dl
SpO2- 98%@RA
CVS - S1 S2 +VE
RS -BAE +VE , NVBS +VE
P/A - soft , non tender , BS +ve
CNS - No nystagmus , sensory decreased (L<R)-fine touch , temperature , vibration .
Rombergs -ve
A-
Giddiness under evaluation secondary to
a) HTN ? b)Autonomic neuropathy ? with denovo HTN with hyperternsive retinopathy with k/c/o DM -2 with diabetic neuropathy
P-
INJ METOCLOPROMIDE 2CC IV/BD
INJ. ZOFER 4MG /IV/TID
INJ.PAN 40MG /IV/OD
INJ. HAI ACC TO SLIDING SCALE (8AM -2PM-4PM)
T. PROMETHAZINE 25MG PO/TID
T.VERTIN 16MG PO/TID
T.DOLO 650MG PO/TID
Day 2
AMC
Bed no 2
S-c/o giddiness + , no c/o vomitings
AMC
Bed no 2
S-c/o giddiness + , no c/o vomitings
O-
patient is c/c/c
Temp - Afebrile
PR - 90bpm
BP - Supine -120 mmHg
Sitting -110mmHg
RR -14cpm
GRBS -152 mg/dl
SpO2- 98%@RA
CVS - S1 S2 +VE
RS -BAE +VE , NVBS +VE
P/A - soft , non tender , BS +ve
CNS - No nystagmus , sensory decreased (L<R)-fine touch , temperature , vibration .
Rombergs -ve
A-
Giddiness under evaluation secondary to
a) HTN ? b)Autonomic neuropathy ? with denovo HTN with hyperternsive retinopathy with k/c/o DM -2 with diabetic neuropathy
P-
INJ. ZOFER 4MG /IV/TID
INJ.PAN 40MG /IV/OD
INJ. HAI ACC TO SLIDING SCALE (8AM -2PM-4PM)
T. PROMETHAZINE 25MG PO/TID
T.VERTIN 16MG PO/TID
T.DOLO 650MG PO/TID
