71M with Giddiness and nausea since yesterday
This is a history of 71 M who is a drama director by occupation. His history dates back to 2017 when he first developed shortness of breath where he couldn't even walk more than 20 steps (grade 3) and is associated with increased efforts to take air in, he also gives history of heavy bound palpitations. He gives negative history for pedal edema, cough,cold,fever, night sweats,weight loss at that time. And for his shortness of breath he first came to KIMS hospital and here they got to know that his ecg was abnormal (findings unknown) and they were referred to higher centres in view of need for cardiologist. They went to another hospital in Hyderabad where the cardiologist suggested an angiography. They agreed for it and the result came out to be blockade of three vessels to the heart according to patient's attendant words(patient's wife). For which he had undergone Coronary artery bypass grafting. Later the patient with his attenders repeatedly visited the hospital for follow up on doctors advice. He didn't show any worrisome problems until yesterday. He came to casualty yesterday evening with complaints of giddiness and nausea from 2 pm in the afternoon.This episode was sudden in onset and began after he had a heavy lunch. Patient's attendants also noticed he had profuse sweating at that time for which they got worried and consulted a local doctor and were told the giddiness was because of high blood pressure and patient was given Tab vertin. But the giddiness didn't subside so they decided to opt our hospital and while he was travelling to our hospital he gives history of 2 episodes of vomiting (non bilious,non projectile,non foul smelling, associated with food particles).
He has no history of ringing sensation in the ears, ear pain, any discharge from the ears or foreign body sensation in the ears. Patient gives a 3 year history of left sided hearing loss.
No history of headache,involuntary movements,Loss of consciousness.
No history of pain abdomen,loose stools,no bleeding per rectum.
No history of chestpain,palpitations, shortness of breath at the time of presentation.
Patient had another episode of vomiting in the hospital with food particles as its contents.
He was diagnosed with hypertension at the time of his hospitalization for shortness of breath I.e 2 and half years back and he is on regular medication (Carvedilol).
Patient takes mixed diet, sleep is adequate,bladder movements are regular, no additictions. Patient has difficulty in passing stools.
Patient's mother was also diagnosed with Triple vessel disease at 72 years of age and was suggested CABG but she refused and opted for medical therapy.
At the time of presentation
O/E: Patient was conscious, coherent,cooperative, well oriented.
Vitals :BP-160/90 mm Hg
Tab. Nicardia 10 mg po was given.
PR:95bpm
Spo2:98%
GRBS:142 mg/dl
S/E :
HINTS examination reveals-
Horizontal bidirectional nystagmus and positive vertical skew with delayed saccades
CNS : Higher mental functions are normal
Cranial nerves are intact.
Power :5/5 in both UL and LL
Tone : normal
Reflexes : exaggerated in both UL and LL
Plantar - flexor
Sensory system : normal
Gait : Ataxic
CVS : S1,S2 heard,no murmurs.
RS : BAE +,NVBS, no additional sounds.
P/A : soft, Non tender, no organomegaly, bowel sounds heard.
Diagnosis - Class III NYHA with HFpEF with Triple Vessel Disease S/P CABG with ? Cerebellar TIA with Microcytic Hypochromic Anemia under Evaluation.
On Day 1 :7/11/2020
Bp:150/70 mm Hg
PR:64 bpm
Grbs-114mg/dl
Stools passed
CVS:S1,S2 heard, no murmurs
RS:BAE+,no additional sounds
PA:soft,non tender
2d ECHO was done
MRI was done which turned out to be normal.
