A 65 year old POSTURAL DIZZINESS AND VOMITING

65Year old female POSTURAL DIZZINESS AND VOMITING

December 03, 2023

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63 year old housewife from Nalgonda

Chief complaints- Vomiting 5 episodes 3 days ago

History of present illness-

Patient was apparently alright 1 year back then developed vomiting associated with giddiness and pain. she came to our hospital and vomiting subsided with treatment. She was asked to take Vertin 24 (betahistine) at discharge. she took the medication for 3 months and then stopped after consulting with her physician. She had mild episodes of vomiting for the next months until 3 days back when she had 5 episodes (severe)

Vomiting- non projectile, contents were food/watery. there was no blood present in the vomitus. no temporal association with meal timings was noticed. it was associated with giddiness and colicky, non radiating pain in the epigastrium, present only during the episode. Not associated with fever, headache, diarrhoea or constipation.

Frequency of stools are normal but volume is decreased due to less food intake out of fear of vomiting.

No history of- abdominal distention, heart burn, acidity, excessive flatulence, jaundice.

Giddiness- there was no history of headache, trauma, fall, stroke, aural fullness, tinnitus, no positional variation or triggering factors (starts randomly). no aggravating factors. relieved with medications.

Past history-

Patient is a known case of hypertension since 5 years, is on medication Telma 40.

No history of tuberculosis, diabetes mellitus, stroke.

Personal history-

Mixed diet

Reduced appetite

Adequate sleep

Bowel movements are of normal frequency but reduced volume

Bladder movements are normal

No addictions or allergies

Occasionally drinks toddy.

Daily routine (premorbid)

0500- wakes up

0500-0600- gets ready

0730- Chai + bun

0730- 1300- stays indoors, doesn't do much

1100- Rice+ curry

1300- Buttermilk+rice

1300-2000- stays indoors, doesn't do much

2000- Rice+curry

morbid changes- doesn't eat much due to fear of vomiting, however, small meals are consumed regularly.

Family history- No similar complaints in the family. no history of HTN or DM in the family.

General examination-

Patient is concious coheret cooperative and oriented to time place and person.

built- average

nourishment- average

Pallor is present, icterus, cyanosis, clubbing, lymphadenopathy or edema are absent.

Temperature- Afebrile

PR- 78 bpm, regular, normal volume, normal character, no radioradial delay, no radiofemoral delay.

RR- 17 cpm

BP- 130/80 mmHg

Decreased range of motion of neck flexion

Fixed flexion deformity of bilateral knees with left being more then right

Systemic examination-

Per Abdomen-

Inspectionshape- flat

flanks- empty

umbilicus- inverted

striae gravidarum present.

normal movements with respiration

no visible pulsations, peristalsis, or hernial orifices

abdominal girth-

palpation-

no local rise of temperature or tenderness in any quadrant. no guarding or rigidity. liqver and spleen were non palpable.

Percussion- no shifting dullness or fluid thrill present.

Auscultation- Bowel sounds heard.

Central nervous system-

Concious, Coherent, Cooperative, orientated to time, place, person

memory- recent memory impaired

speech- Normal

Gait- short steps with broad bas

cranial nerves-

1- Smell intact

2- Counting fingers+ menace reflex+

3, 4, 6-External ocular movements- full and free, accomodation reflex +

5- Sensations on face normal. able to open jaw against resistance.

7- Movements of face normal

8- Rinne's test negative with 512, Weber's test negative

9, 10, 11- gag reflex on both sides present, no uvula deviation, normal swallowing, shrugging of shoulders against resistance+

12- No deviation of tongue.

Motor-

RIGHT LEFT

Bulk- UL 26cm 26cm

LL 41cm 39cm

Tone- UL N N

LL bilateral hypertonia (quadriceps and gastrocnemius)

Power- UL 5 5

LL 4 4

Reflexes- Biceps 3 2

Triceps 2 2

Supinator 2 2

Knee 1 1

Ankle 1 1

Plantar 1 1

sensory- UL LL

Fine touch- N decreased

crude touch- N decreased

pain- N N

temperature-

vibration sense- N decreased

proprioception- N decreased

2 point discrimination 20cm unable to ellicit

stereognosis intact

Cerebellar-

Finger nose test- slow

Knee heel test- slow

Dysdiadochokinesia- slow

Neck stiffness- present

kernig sign- absent

bruzdinki sign- absent

Romberg test- positive