A 60 year old woman presented with complaints of giddiness

17 April 2023

E LOG GENERAL MEDICINE 

Hi, I am Naalla Gayathri , 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”


I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Date of admission - 15th April 2023

CHIEF COMPLAINTS:
Patient complaints of giddiness and fainting from 3 months.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months back.She got 1st episode of giddiness and fainted at that time while going to washroom.She  immediately got conscious.
It is not associated with headache, nausea, vomiting .
And one more time she experienced this in home and 3rd time 1 month back she experienced same giddiness and fainted which resulted in fracture of wrist and leg.
She experiences giddiness while sleeping or change in position of head.
She changed her antihypertensive drug 6 months back(present atenolol).

PAST HISTORY:
Undergone hysterectomy 35 years back.
Known case of hypertension since 30 years.
Undergone knee surgery for both legs 7 years back.
Undergone surgery for both eyes 3 years back.
No history of diabetes, asthma, tuberculosis, epilepsy, thyroid.

PRESENT HISTORY:
Diet:mixed
Appetite: normal
Sleep: adequate
Bowel: regular 
Bladder: regular
Addictions: None

FAMILY HISTORY:
No significant family history.

ALLERGIEC HISTORY:
No known allergies.

GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Pallor - absent.
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No edema

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