65 YEARS OLD FEMALE WITH SYNCOPE

 This is an online e log book to discuss our patient's de-identified health data shared after taking his/her/guardians' signed informed consent. This Elog reflects my patient-centered online learning portfolio.

A 65 year old female, housewife, resident of Chinatunalgudam presented to the casualty with loss of consciousness.


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic two days ago. Then, after walking for a long time, she had an episode of syncope, associated with sweating,  

After gaining consciousness after approximately.

Not associated with palpitations, flushing, chest pain, muscle weakness, slurring of speech, headache. 

The patient was brought to the casualty and given medication (glucose saline) and recovered completely.


PAST HISTORY:

4 days ago, patient has history of chest pain (sudden onset , in the centre of chest, squeezing type, non progressive, not radiating ) with shortness of breath following exertion, which was relieved on rest. 

She went to an RMP and was given an anti-hypertensive agent. (which she consumed for the first time 3 days ago)


No similar complaints in the past 

She is a known case of hypertension since 3days 

Not a known case of diabetes mellitus, asthma, tb, cerebrovascular accidents, coronary artery disease .

No blood transfusions .

History of treatment for cellulitis of leg 3 years back.


FAMILY HISTORY:

3 siblings with DM


PERSONAL HISTORY:

Mixed diet , normal appetite 

Adequate sleep 

Normal bowel and bladder movements 

No allergies 

Addiction - sutta- 4 cigarettes/ day since 40 years 

Alcohol or toddy - 1 glass daily 


MENSTRUAL HISTORY:

Age of menopause: 48 years of age


GENERAL EXAMINATION:

The patient is conscious, coherent, and cooperative 

Moderately built and moderately nourished 


There is no Pallor, icterus, cyanosis, koilonychia, lymphadenopathy. 

Pedal edema present till  below knee












VITALS:

BP- 120/80mmHg in sitting position with cuff in the right hand at the level of the heart 

PR- 67 bpm, normal in rhythm, rate, volume and character. No radioradial / radiofemoral delay

RR- 20cpm

Temp- Afebrile 


SYSTEMIC EXAMINATION:

CNS:


Higher Mental Functions 

Normal speech and language 

Normal memory 

No delusions or hallucinations 

Cranial nerve examination 

I: Intact bilaterally 

III, IV, VI: Extraocular movements free and full bilaterally 

V: Intact bilaterally 

VII: Intact bilaterally 

VIII: No nystagmus, intact bilaterally 

IX,X: Intact bilaterally 

XII: Intact bilaterally 


MOTOR SYSTEM 

Bulk- normal  

Power: normal.  Power of:

- Shoulder , Elbow , Wrist , Smalll muscle of hand and hand grip bilaterally 

- knee , ankle  bilaterally 

Muscle tone: normal 

Reflexes - Biceps , triceps , knee jerk , ankle jerk bilaterally - +2

Cerebellar signs: Absent


Sensory system examination 

Upper limb: 

- Crude touch, temperature, fine touch, vibration sensation present bilaterally 

- Pain sensation is normal bilaterally  

Lower limb:

- Crude touch, temperature, fine touch, vibration sensation present bilaterally 

- Pain sensation is normal bilaterally  


CVS 

S1 S2 heard , no murmur 

No thrill 

Apical impulse felt 


RESPIRATORY 

Normal vesicular breath sounds in all areas 

No adventitious breath sounds


PER ABDOMEN 

Obese abdomen, umbilicus central and everted 

Soft , non tender 

No hepatomegaly no splenomegaly 


INVESTIGATIONS:









PROVISIONAL DIAGNOSIS:

?Heat exhaustion 

?TIA 

?Hypotension 


Daily routine 

Wake up - 7 am

8 am - breakfast (rice )and tea 

Afternoon - lunch ( rice and curry ) 

Dinner - 9pm rice and curry .

Sleep - 10 pm


SOAP NOTES:



TREATMENT:


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