A 55 year old patient with giddiness and vomitings

      A 55 year-old female patient ,who is a homemaker by occupation and resident of AP.Lingotam presented with ,

  C/O giddiness and vomitings at yesterday after 4pm.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic yesterday morning (27-07-22),and then later in the evening ,while eating she had an episode of vomiting and then she felt giddy and lost her consciousness ,followed by 2 more episodes of vomitings and slurring of speech.Immediately she was taken to the local hospital and then her blood pressure was 170/90 .She was referred here .The 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 :none

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 







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