27 year old male with chief complaints of headache and dizziness
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A 27 year old male who works in printing press came to hospital with chief complaints of:
Headache since 4 years
Syncopal attack since 4 years ,last episode was 10 days ago.
HOPI:
Patient was apparently asymptomatic 4years back then he developed headache which is sudden in onset,gradually progressed in occipital region to neck not associated with nausea and vomitings it aggrevated by lifting heavyweights and climbing stairs and relieved spontaneously.
Syncopal attack was 5 to 6 episodes ,last attack was 10 days ago, where loss of consciousness was around 5 minutes,there is no post icteal confusion.in the last episode he had tingling sensation in the ears.
No h/o nausea,vomitings.
He had fever yesterday in the evening which is insidious in onset.
H/o palpitations associated with sweating,chest tightness,aggrevated when heard any dearh news and relieved spontaneously.
H/o of stomachpain in epigastric region since one and half year which is burning type of pain,increases immediately after taking food relives after 1 to 2 hours.
H/o of bleeding per anus occasionally since 1 year, with painful defeacation.
H/0 of dyspnea while climbing stairs.
Past history:
Not a known case of DM,HTN,CAD,CVA,TB,Asthma,Epilepsy
He had history of RTA 4 years back while he was driving a bike.he hit to the divider .He was taken to the hospital and there swelling at occipital area.There was no bleeding.he had seizures and loss of consciousness.Head CT was done and it was normal.After that one day he was lifting heavy weights he started getting headache, palpitations,stomach pain.that was the first episode.headache was persistent for a week and he did not take any medication.he tried to sleep whenever he had headache.
3 years back his father passed away due to heart attack.After that incident he gets palpitations associated with sweating, when heard any sad news,and any death related incidents.
He consulted doctors and taking medications for palpitations.His used to get palpitations and sweating.
He got COVID 19 in 2022 jan, and taken treatment at home.
Family history:
No similar complaints in family he stays with his mother ,paternal grandmother, sister.after his father passing away he became bread winer of the family.
Daily routine:
Patient wakes up around 9:00 and does his morning chores and he ll have his breakfast.sometimes he misses his breakfast and goes to shop.he owns a printing press and works there till evening.he ll have his lunch at 1pm which is mostly rice and curry .he comes to home around 7 pm and have dinner around 8pm.he ll go bed around 10 pm but he sleeps at 2am with disturbed sleep.
Personal history:
Diet: vegetarian
Appetite: decreased since 1 year( eats only 2 times a day)
Sleep: disturbed sleep
Bowel: sometimes blood in stools
Bladder: regular
No addictions
He studied upto 10 th class and stopped his education due to his family problems and financial status
GENERAL EXAMINATION:
Patient is concious ,coherent,cooperative .Moderately built,Moderately nourished.
signs of pallor is present
No signs of icterus, clubbing, cyanosis, lymphadenopathy, edema.
Temp-Afebrile
BP- 110/70 mm hg
PR - 82 bpm
RR - 16 cpm
CNS EXAMINATION:
Higher mental function :intact
Speech: normal
No illusions or hallucinations
No signs of meningitis.
Gait: normal
Cranial nerve examination:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : normal
5th : sensory intact
motor intact
7th : normal
8th : No abnormality noted.
9th,10th : normal
11 th : intact
12 th : normal
Motor system examination:
Right. Left
Bulk: Normal Normal
Tone:
Upperlimb. Normal. Normal
Lowerlimb. Normal Normal
Reflexes: biceps. +. +
Triceps. +. +
Supinator. +. +
Knee. +. +
Ankle. + +
Plantar Flexion. Flexion.
Sensory system:
All sensations are intact
RESPIRATORY SYSTEM
inspection:
Trachea appears to be normal - Central
shape of chest - elliptical
Movements of chest appear to be bilaterally equal
No scars , sinuses present.
No drooping of shoulder
No engorged veins , swellings seen
No hallowing seen
No crowding of ribs
Palpation:
All inspectory findings are confirmed
No rise of temperature
No tenderness
Trachea is in midline
B/L chest movements are equal
No swelling and palpable masses are felt
vocal fremitus are normal
PERCUSSION. RT. LT
SUPRA CLAVICULAR resonant. resonant
INFRA CLAVICULAR. resonant. resonant
MAMMARY. resonant. resonant
INFRA MAMMARY. resonant. resonant
AXILLARY. resonant resonant
INFRA AXILLARY. resonant resonant
SUPRA SCAPULAR. resonant resonant
INFRA SCAPULAR. resonant resonant
INTER SCAPULAR. resonant resonant
Auscultation:
Vesicular breath sounds
SUPRA CLAVICULAR NVBS. NVBS
INFRA CLAVICULAR. NVBS. NVBS
MAMMARY. NVBS. NVBS
INFRA MAMMARY. NVBS. NVBS
AXILLARY. NVBS. NVBS
INFRA AXILLARY. NVBS. NVBS
SUPRA SCAPULAR. NVBS. NVBS
INFRA SCAPULAR. NVBS. NVBS
INTER SCAPULAR. NVBS. NVBS
Per abdomen:
Inspection -
Shape of abdomen : scaphoid
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation -
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion -
Resonance note heard
On auscultation -
Bowel sounds heard
Cardiovascular system:
Inspection-
No raised JVP
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Auscultation-
S1 and S2 heard, no murmurs are heard .
INVESTIGATIONS:
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