50/F with DRY COUGH AND GIDDINESS
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
A 50 years female patient farmer by occupation , resident of nalgonda came to casuality with chief complaints of
-Dry cough since 3days
-Giddiness and palpitations since past 2 days
HISTORY OF PRESENT ILLNESS :-
Patient was asymptomatic 5years back and then developed high grade fever and associated with chills for which she went to hospital and was treated conservatively and also had giddiness at that time for which she was known yo be having HTN and using medication. since then asymptomatic till 7/8/22 evening 5pm and developed giddiness and palpitation.
PAST HISTORY:
Patient is a known case hypertension ,since 5 years and on medication.
Not a known case of tuberculosis, asthepilepsyepsy
PERSONAL HISTORY:
Diet - mixed
Appetite-Normal
Bowel and Bladder movements-Regular
Sleep-adequate
#Addictions
- Occasionally toddy drinker since 20years
- Betel leaf since 20years
FAMILY HISTORY::
Not significant
ON EXAMINATION:
Patient was conscious, coherent, cooperative and we'll oriented to time place and person
GENERAL PHYSICAL EXAMINATION:
Pallor-present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Generalized lymphadenopathy- absent
Vitals**
Temperature- Afebrile
Pulse rate -96bpm
Resp rate - 14cpm
Blood pressure-190/80mmHg
sPo2 98% at room temperature
GRBS - 106 mg
SYSTEMIC EXAMINATION
CVS:
Inspection
Chest wall is bilaterally symmetrical.
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscaltation
S1&S2 are heard,no murmur found.
RESPIRATORY SYSTEM
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds
CNS
Patient is conscious
Speech normal
No signs of meningeal irritating
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
PER ABDOMEN
**Shape of abdomen-scaphoid
**Tenderness-No
** Palpable mass-No
** Liver- Not palpable
**Spleen - Not palpable
**Bowel sounds - No
PROVISIONAL DIAGNOSIS::
*HYPERTENSIVE URGENCY**
INVESTIGATIONS
CBP
#BLOOD UREA
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