27 year old male with headache and dizziness

 This is the case of a 27-year-old male, a worker at a printing press, who presented to the hospital with chief complaints of 

  • Headache since 1 year 
  • Dizziness since 1 year 
History of presenting illness 

The patient was apparently asymptomatic 3 years ago. 

3 years ago, the patient met with a road traffic accident. There was a history of head injury for which the patient underwent a CT scan. No abnormality was found on the CT. 
Since three years, the patient has had alternating nasal blockage and reduced quality and quantity of sleep. 

In February 2022, The patient experienced sudden onset of palpitations, with discomfort in the chest, and mild sweating for which a 2-D ECHO was done which depicted tachycardia, Mitral and tricuspid valve regurgitation. The patient was prescribed Clonazepam, Vit B12, Beta-blockers and sucralfate syrups. The patient still complains of palpitations and increased heart rate during dizziness. 

1 Year ago, in May 2022, the patient experienced a headache for the first time. The headache was sudden onset, throbbing and pulsatile in character and lasted one week. The pain was present at the centre of the head and the occiput. The patient has continued to have similar episodes for 1 year, these episodes last for 3- 4 days a week. The headache is relieved slightly on rest and consumption of propranolol (prescribed by an RMP following one such episode . ). The patient experiences noise intolerance whenever he has a headache. 

The headache is associated with pain in the left lower ribs and left hypochondrium. It is continuous, and dragging in character and lasts till the headache persists. 

There is no aura, photophobia, agitation during the episode, chronic medication use, physical or mental stressors, lacrimation or rhinorrhoea, or fever. 

Since the past year, with the occurrence of the headache, the patient experienced dizziness. The patient describes his episodes as one with intense sweating, blackout, and increased heart rate. The dizziness is aggravated while climbing stairs and lifting heavy weights and relieved on rest. It is associated with shortness of breath and weakness. 

During the episodes, the patient has had to take a leave from work, due to the severity of the pain.


History Of past Illness 

History of anterior Myocardial infarction in 2022. 
The patient is not a known case of diabetes mellitus , Hypertension, Tuberculosis , Epilepsy 

Treatment History 
- Propanolol 
- Cobalmin 
- Clonazepam 
-Sucralfate syrup

Previous Investigations 


Personal History
 
Diet: vegetarian 
Appetite reduced 
Bowel movements: Increased frequency since last 10 days 
Bladder movements : Normal 
Sleep- Reduced quality and quantity of sleep 
Addictions: None 


Family History 

Father: History of CAD 
Uncle: Kidney disease 


General Examination 

The patient is conscious coherent, oriented to time place and person. 

The patient is moderately built and moderately nourished 

Vitals : 
- Blood Pressure: 130/90 mmHg 
- Temperature: afebrilele 
- Respiratory Rate: 18 CPM - 
- Pulse - 74 BPM 


Absence of Pallor, Icterus, Cyanosis, clubbing, koilonychia, Lymphadenopathy, oedema 




CNS Examination 


Higher mental functions: Normal 

Cranial Nerve examination: no abnormality found, bilaterally 

Motor system examination: In both upper and lower limbs 
- Bulk : normal 
- Tone : Normal 
- Power : Normal 
- Deep tendon reflexes : 
-Present Bilaterally 
- Gait : normal 
- Absence of involuntary Movements 

Sensory System : Checked bilaterally 
-No abnormality in fine touch , vibration sensation, proprioception , romberg's sign , crude touch, pain , temperature ,two-point discriminaion and sterognosis 

Cerebellar signs : no abnormality 

CVS examination 
- S1,S2 heard no thrills or murmurs 

Respiratory system examination 
- Normal vesicular breath sounds 
- Trachea in central Position 

Per abdomen : 
Soft , non tender , no organomegaly, ascites 


Diagnosis : ? Anxiety disorder

The patient was referred to psychiatry in view of the described symptoms 

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