Giddiness

1. PHYSICIAN CONFERENCE
22nd June 2023
First Medical Unit
AN INTERESTING CASE OF GIDDINESS
Chief and HOD- Prof. Dr.Rajagopala Marthandam MD.,

2. NAME - Kasiraja
AGE - 53 years / Male
OCCUPATION - CASHIER AT HOTEL
ADDRESS - TENKASI
PATIENT DETAILS

3. ● Giddiness * 5 years
● Excessive sweating * 5 years
● Inability to ejaculate * 4 years
● Inability to develop erection * 1.5 years
CHIEF COMPLAINTS

4. HISTORY OF PRESENTING ILLNESS
● Patient was apparently normal 5 years back after which he developed giddiness on standing from sitting and
lying position, which was initially relieved within 15-20 seconds of standing then progressed gradually that the
giddiness at present persists even after 5 minutes of standing
● History of excessive sweating with associated cold clamminess on left half of the body (below the neck and
above the waist) for the past 5 years
● One year after the onset of giddiness, patinet gives history of inability to ejaculate during sexual intercourse but
was able to maintain erection
● Patient is unable to have erection for the past 1.5 years
● No History of Loss of consciousness
● No History of vertigo / tinnitus / ear discharge / fullness of ears
● No History of weakness / tiredness

5. ● No History of nausea
● No History of anxiety
● No History of passing turbid urine
● No History of nocturnal diarrhea / difficulty in salivation / Lactimation
● No History of LOC / seizures / memory / speech disturbances
● No history of delusions / hallucinations
● No history of sleep disturbances
● No history suggestive of any involvement of cranial nerves
● No history suggestive of weakness of limbs / trunk
● No history suggestive of sensory disturbances
● No history of features suggestive of cerebellar involvement
● No history of involuntary movements
● No history of bowel bladder disturbances
● No history of fever / neck stiffness / vomiting / blurring of vision / seizures
● No history of trauma / vaccination in the recent past
● No history chest pain / palpitations / breathlessness

6. PAST HISTORY
• Not a known case of Diabetes Mellitus, Systemic Hypertension, Bronchial
Asthma, Tuberculosis, Epilepsy, Hypothyroidism, Chronic Kidney Disease
• Patient presented to the Cardiology department for his complaints of
giddiness and underwent CAG and was found to have Single Vessel Disease
with 70% occlusion of Right Coronary Artery and Ejection Fraction of 66%
• No H/O similar episodes in the past
• No H/O Trauma / No H/O recent vaccination

7. PERSONAL HISTORY
● Smoker and alcoholic for the past 30 years - Consumed 1.5 packets of Cigarette
(approximately 15 per day) and 180ml of Alcohol per day daily
● Stopped smoking and alcohol consumption one month back
● Consumes both vegetarian and non-vegetarian diet
● Normal Bowel Bladder Habits
● Normal Sleep wake cycle
● Normal appetite
MARITAL HISTORY
● Married at the age of 32 years
● One son (15 years) and daughter (10 years)

8. GENERAL EXAMINATION
• Conscious
• Oriented to time, place and person
• Afebrile
• Not tachypneic
• No pallor/ icterus/cyanosis/clubbing/pedal edema/lymphadenopathy
• No neurocutaneous markers
• Pulse : 56/min, Normal volume, no specific character, peripheral pulses felt
equally
• Blood Pressure : 120/80mm Hg in supine position
• spO2 : 98% in RA
• Respiratory Rate : 16/min

9. ● HIGHER MENTAL FUNCTION
○ Conscious
○ Oriented to time, place, person
○ Right handed individual
○ Memory : Immediate, Recent, Remote Memory Intact
○ Speech and language normal
○ Attention and calculation normal
EXAMINATION OF CNS

10. CRANIAL NERVES
RIGHT LEFT
1 Olfactory Smell Normal Normal
2 Optic Visual acuity
Field of vision
Colour vision
Normal
Normal
Normal
Normal
Normal
Normal
3,4,6 Oculomotor
Trochlear
Abducent
Palpebral fissure
Extra ocular movements
Pupil size
Direct & indirect light reflex
Accommodation
Normal
Normal
3mm RTL
Normal
Normal
Normal
3mm RTL
Normal
5 Trigeminal Sensations over face
Clenching of teeth
Corneal reflex
Conjunctival reflex
Jaw jerk
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

11. RIGHT LEFT
7 Facial Wrinkling of
forehead
Tight closure
of eyelid
Blowing of
cheeks
Nasolabial
fold
Taste
sensation
anterior 2/3 of
tongue
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
8 Vestibulocochlear Rinne’s test
Weber test
AC>BC
No lateralization
AC>BC

12. RIGHT LEFT
9, 10 Glossopharyngeal
Vagus
Uvula - Midline
Ah test
Palatal reflex
Pharyngeal reflex
Normal palatal
elevation
Normal
Normal
Normal palatal
elevation
Normal
Normal
11 Spinal accessory Shrugging of
shoulder
Turning of head
Normal
Normal
Normal
Normal
12 Hypoglossal Tongue protrusion
Movement against
cheek
Fibrillations
No deviation
Normal
Absent
Normal

13. MOTOR SYSTEM
BULK RIGHT LEFT
UPPER LIMB
Arm
Forearm
24
20
25
20
LOWER LIMB
Thigh
Leg
50
32
49
33
No intrinsic muscle wasting No intrinsic muscle wasting
TONE RIGHT LEFT
Upper limb Normal Normal
Lower limb Normal Normal

14. Shoulder joint Flexion
Extension
Abduction
Adduction
Medial rotation
Lateral rotation
5
5
5
5
5
5
5
5
5
5
5
5
Elbow Flexion
Extension
5
5
5
5
Wrist Flexion
Extension
5
5
5
5
Hand grip 100% 100%

15. POWER RIGHT LEFT
Hip joint Flexion
Extension
Abduction
Adduction
5
5
5
5
5
5
5
5
Knee Flexion
Extension
5
5
5
5
Ankle Dorsiflexion
Plantar flexion
5
5
5
5
Toe Flexion
Extension
5
5
5
5

16. SUPERFICIAL REFLEXES RIGHT LEFT
Corneal Present Present
Conjuctival Present Present
Palatal Present Present
Pharyngeal Present Present
Abdominal Present Present
Cremasteric Present Present
Plantar Flexor Flexor
DEEP TENDON REFLEX RIGHT LEFT
Jaw Jerk Present +
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 1+ 1+
Knee 2+ 2+
Ankle 1+ 1+

17. SENSORY SYSTEM
RIGHTS RIGHT LEFT
Fine touch Able to perceive equally
Crude touch Able to perceive equally
Pain Able to perceive equally
Temperature Able to perceive equally
Vibration Able to perceive equally
Proprioception Able to perceive equally
Cortical sensation Normal
No Saddle Anesthesia

18. CEREBELLAR FUNCTION TESTS
Right Left
Finger nose test Normal Normal
Finger nose finger test Normal Normal
Alternate supination and pronation Normal Normal
Tandem Walking Normal
Heel knee test Normal Normal
Romberg’s test Negative
No Nystagmus
No Intentional Tremors

19. Supine After 1 min of
standing
After 3 min of
standing
After 5 min of
standing
Blood Pressure 120/80 60/40 60/40 60/40
Pulse 52/min 88/min 92/min 94/min

20. ● No neck stiffness
● Kernig’s Sign - Negative
● Gait - Normal
● No spinal deformities / tenderness

21. ● CVS – S1,S2 heard, no murmur
● RS – Vesicular breath sounds heard
● Abdomen – soft, no organomegaly

22. Date 12/06/2023
TC 8200
RBC 4.40
Hgb 12.4
PCV 40.1
Platelets 1.60 Lakhs
INVESTIGATIONS
Date 12/06/2023 13/06/2023
RBS 84 112
Urea 27.5 38.2
Creatinine 1.29 1.38
Na 139 137
K 3.7 4.1

23. DATE 12/06/2023
TOTAL
BILIRUBIN
1.5
INDIRECT
BILIRUBIN
0.4
DIRECT
BILIRUBIN
1.1
SGOT 31
SGPT 45
ALP 204
PROTEIN 6.8
ALBUMIN 3.8
GLOBULIN 3.0
ICTC Non-Reactive
Total Cholesterol 130 mg/dl
Triglycerides 110 mg/dl
HDL Cholesterol 28 mg/dl
LDL Cholesterol 80 mg/dl
CHO / HDL Ratio 4.64

24. USG ABDOMEN PELVIS
● Grade I Fatty Liver
● Normal Renal echoes with maintained CMD
ECHO
● Hypokinesia of distal 2/3rd of IVS and LV Apex
● EF - 66%
● Adequate LV Systolic function

27. ● Relevant radiological imaging done
● All relevant opinions obtained
● Case is open for discussion

28. THE CASE IS OPEN FOR DISCUSSION