65 YEARS OLD FEMALE WITH SYNCOPE .

Siddam sushmitha

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.

This is the case of a 65 years old lady housewife, resident of Chinatunalgudam.


The patient presented to the casualty on Thrusday (30/11/2023) after episode of loss of consciousness .


 Patient was apparently asymptomatic two days ago , then she had an episode of syncope  , associated with sweating , and after walking for a longer period of time . 

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

The patient was brought to the casualty and given medication and recovered completely  .

6 days ago - History of chest pain which was sudden in onset , in the centre of chest , squeezing type , non progressive , not radiating and with shortness of breath following exertion , which were both relieved on rest . 

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


PAST HISTORY 

No similar complaints in the past 

She is a known case of hypertension since 3days 

Not a known case of Diabetes Mellitus , Asthma , TB,CVD,CAD

No history of  blood transfusions .

History of treatment for cellulitis of leg was taken by the patient . 


FAMILY HISTORY 

Family history shows patient's 3 sibilings 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 


GENERAL EXAMINATION 

The patient is conscious , coherent and cooperative 

Moderately built and moderately nourished 


There is absence of Pallor , icterus cyanosis,  koilonychia, lymphadenopathy . 

Pedal edema present 








VITALS 

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

PR- 67 bpm, normal rhythm , 

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 

-normal  : Biceps , triceps , knee jerk , ankle jerk bilaterally 

Cerebellar signs : Normal 


Sensory system examination 

Upper limb : Normal 

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







PROVISIONAL DIAGNOSIS 

?Heat exhaustion 

?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


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