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


CUE
LFT


SERUM CREATININE
SERUM ELECTROLYTES
#THYROID PROFILE


#ANTI HCV ANTIBODIES

2DECHO



ECG

Treatment::


Tab.amlong 5mg PO/OD

Tab.nicardia 10mg stat

Tab.vertin 16mg PO/BD

BP charting (2nd hourly)











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