55Yr Female with Giddiness

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 A 55 Yr old female patient from A.P.Lingotam,homemaker by occupation presented with complaints of 

Giddiness,headche,neck stiffness from yesterday evening 4pm 

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asympotmatic yesterday (27/07/22)morning. Later in the evening,she felt giddy,headache,neck stiffness and was taken to hospital.There she was prescribed Propranolol when her measured BP was 170/90.When she tried taking the tablet,she vomited twice and slight slurring of speech was began and was immediately brought here.Patient was brought here by 7pm.

Not associated with fever 

PAST HISTORY :

No similar complaints in the past.

No h/oDM,HTN,ASTHMA,EPILEPSY,CAD,LEPROSY

Patient has joint pains from past 15 years.Pain is of pricking type 

PERSONAL HISTORY :

Diet : Mixed

Appetite : Good

Bowel &Bladder : Regular

Sleep : Adequate 

Addictions :

FAMILY HISTORY : No member of family has similar complaints 

MENSTRUAL HISTORY : 

Patient attained menopause 7 years back 

TREATMENT HISTORY : 

Patient is on regular medication for joint pains from past 15 years.

GENERAL EXAMINATION :

Patient is conscious,coherent,cooperative 

Pallor - Absent 

Icterus -Absent

Cyanosis-Absent

Clubbing-Absent

Lymphadenopathy-Absent

Edema-Absent

VITALS :

Temperature -Afebrile

Blood pressure-110/70

Respiratory rate-18cpm

Pulse rate -80bpm 

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM : S1 S2 heard.No murmurs 

RESPIRATORY SYSTEM : bilateral air entry present Normal vesicular breath sounds heard.

ABDOMEN : Soft,Non tender.Liver not enlarged.Spleen not palpable.

CNS : No focal deficits 

INVESTIGATIONS 

Hemoglobin -12g/dl

TLC-7600

Platelet count -2,50,000

Blood group - AB+ve

Random Blood Sugar -102mg/dl

CUE - Normal

RENAL FUNCTION TESTS 

Sr.Urea - 24

Sr.Creatinine - 0.7

Sr.Uric acid - 39

Sr.Calcium - 102

Na+ - 136

K+ - 3.7

Cl- - 106

MEDICATIONS 

1) T.Pan 40mg  OD

2) T.Zofer 4mg SOS

3) T.Vertin 8mg BD

4) T.Promethazine 25mg BD

BP Monitoring 4th hourly

PROVISIONAL DIAGNOSIS 

HYPERTENSIVE URGENCY