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Dizziness Assessment and Treatment Plan

The patient presented with dizziness and nausea. On examination, the patient had a Glasgow Coma Scale of 456, blood pressure of 124/74 mmHg, pulse of 57 beats per minute, and respiratory rate of 18 breaths per minute. The assessment was benign paroxysmal positional vertigo secondary to a posterior canalithiasis of the left posterior semicircular canal. The plan was to observe for clinical manifestations of dizziness, order blood and serum tests, and prescribe antihistamines, antacids, and antiemetics with bedrest until symptoms resolved.

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ShintaParamithaPutriSantoso
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36 views1 page

Dizziness Assessment and Treatment Plan

The patient presented with dizziness and nausea. On examination, the patient had a Glasgow Coma Scale of 456, blood pressure of 124/74 mmHg, pulse of 57 beats per minute, and respiratory rate of 18 breaths per minute. The assessment was benign paroxysmal positional vertigo secondary to a posterior canalithiasis of the left posterior semicircular canal. The plan was to observe for clinical manifestations of dizziness, order blood and serum tests, and prescribe antihistamines, antacids, and antiemetics with bedrest until symptoms resolved.

Uploaded by

ShintaParamithaPutriSantoso
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

Subjective objective Assasment Planning

Dizziness PHYSICAL EXAMINATION CLINICAL DIAGNOSIS PLANNING DIAGNOSIS


Nausea General state: weak Dizzines Observation of TTV,
Awareness: Compos Mentis
History of Vertigo GCS: 456 Nausea clinical manifestatio
VAS: 3 DL, BUN, SC, SE
TTV
BP:124/74 mmHg TOPIC DIAGNOSIS PLANNING THERAPY
Pulse: 57x / minute, regular
RR: 18x / minute Canalis Semisircularis Diphenhidramin 1x1 amp
Temperature: 37 ◦C axillar Posterior Sinistra Ranitidine 1x1 amp
MRC : 5/5 5/5 ETIOLOGY DIAGNOSIS Ondansentron 1x1 amp
NERVUS CRANIALIS
N II : VOD / VOS>
BPPV
1/60, Visual field: dbn DIET
N III : PBI 3/3 mm SECONDARY DIAGNOSIS Balance intake nutrition
N III, IV, VI : normal eye KIE
movements
NV : sensory dbn Bedrest until the
motoric m. masseter simetric complaint gone.
N VII : dbn
N VIII : hearing
lateralitation (-)
N IX, X :
dbn
N XI : simetric
N XII : simetric
PHISIOLOGY REFLEX
BPR : +2 / +2
TPR : +2 / +2
KPR : +2 / +2

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