A 15 YEAR OLD FEMALE WITH EPISODES OF GIDDINESS
CHIEF COMPLAINTS:
A 15year old female patient(student- 10th std.) came to OPD with complaints of episodes of giddiness since 2months.
HOPI:
patient was apparently asymptomatic 2months ago, when she experienced giddiness followed by loss of consciousness for less than a minute.
She has experienced similar episodes for 2times while in her school since then.
[On 29/01/2024, she was brought to casualty with complaints of fever(high grade, not associated with chills& rigors, cough, cold)since morning and tingling sensation of upper and lower limbs since 2hours. Fever relieved on its own. She also complained of pain abdomen(dull aching type, around the umbilicus) in the morning. Not associated with nausea, vomiting & loose stools.
Pt. is c/c/c ;
Temp: 98.4F ;
PR; 87bpm;
RR: 17cpm;
GRBS: 104mg/dl;
BP: 110/80mmhg ;
INJ. OPTINEURON 1ampoule- 100ml NS IV STAT given.]
Afterwards pt. again experienced 2more episodes of giddiness.
No postictal confusion, nausea or vomiting.
H/o headaches + occasionally , relieved on medication. Not associated with vomitings, photophobia, photophobia, blurring of vision.
PAST HISTORY:
Not a k/c/o DM, HTN, epilepsy, CVA, CAD, TB, Thyroid disorder.
PERSONAL HISTORY:
Diet -mixed
sleep - adequate
appetite - normal
bowel and bladder- Regular
GENERAL EXAMINATION:
Pt. is c/c/c, moderately built and moderately nourished
Pallor ++
No icterus, clubbing, cyanosis, lymphadenopathy and edema of feet
VITALS:
Temp: Afebrile
BP- 110/70mmhg(supine) ; 100/70mmhg(standing)
PR- 80bpm
RR- 16cpm
SpO2- 99% @ RA
SYSTEMIC EXAMINATION:
CVS - S1 S2 +
RS - BAE +, CLEAR,
NVBS.
CNS EXAMINATION:
Bulk: Inspection: N
Palpation: N
Tone:
R-UL-N, L-UL- N
R- LL- N, L- LL- N
Power:
R-UL:5/5
L-UL:5/5
R-LL:5/5
L-LL:5/5
Reflexes: R. , L.
B: +2, +2
T: +2, +2
S: +2, +2
K: +2, +2
A: +2, +2
P: Flexion, Flexion
Sensory system: NAD
Cranial NS:. intact
Ophthalmology opinion: (for fundusopy)
Vision: Rt. 6/6 Lt. 6/6
IOP: 20. 18
Lids: N. N
Conjunctiva: N. N
Cornea: Clear. Clear
AC: PACD >1/2 CT. PACD >1/2 CT
Iris: NCP. NCP
pupil: NSRL. NSRL
Lens: Clear. Clear
Dilated Fundus examination:
Rt. Eye (6mm). Lt. Eye(6mm)
Media: Clear. Clear
Disc: N size, circular, well defined margins,
PPCRA + (both eyes)
CDR: 0.3:1, HNRR. 0.3:1, HNRR
Vessels: N. N
Macula: FR + FR +
[PACD: peripheral anterior chamber depth; HNRR: healthy neuro-retinal rim,CDR: cup-disc ratio, PPCRA: Pigmented paravenous chorioretinal atrophy, FR: foveal reflex]
INVESTIGATIONS(on 29/01/2024):
