Gm blog - 10/4/2023

A patient of 62 year old female residence of nuthanakal.Came to opd with 
Cheif complaint of generalised weakness since 3days.
History of present illness 
          Patient was apparently asymptomatic 3days back and then developed generalised weakness.She is a known case of hypertension since 6 years and on regular medication.
No history of blurring vision,pedal edema, headache,neck pain,chest pain,shortness of breath, palpitations,pain abdomen,nausea, vomiting.
History of past illness
Patient is a known case of hypertension since 6years and is not a known case of diabetes,asthma, epilepsy, tuberculosis and pedal edema.
Family history
Not significant
Personal history
Patient is a vegetarian with normal appetite, adequate sleep and regular bowel and bladder habits,no allergies,not an alcoholic.
Treatment history
On medication with Tab. Atenolol 50mg and Tab.Amlodipine 5mg
History hysterectomy surgery
History of blood transfusion
General examination
Patient is conscious, coherent well oriented to place and time.
Weight:53kgs,  height:160 cm
Pallor: present     cyanosis:absent
Icterus:absent      clubbing: absent
Edema: absent.    Lymphedenopathy:absent 
Temperature: 98.2F 
Pulse rate. :64 beats per min
Respiratory rate:16cycles per minute
Blood pressure: 130/80 mmHg
Systemic examination
CARDIOVASCULAR SYSTEM
S1,S2 heard,no thrills and murmers heard.
RESPIRATORY SYSTEM
No dyspnea and wheeze present 
Position of trachea is central
Breath sounds are vesicular
ABDOMEN 
Shape of abdomen is scaphoid 
No tenderness is present
No palpable mass is present
Hernial orifices are normal
Liver and spleen are not palpable
CENTRAL NERVOUS SYSTEM
Patient is conscious with normal speech 
No signs of meningeal irritation such as neck stiffness
Cranial nerve examination,motor system and sensory system are normal
Provisional diagnosis: Hypertension.
Investigation: 
Ultrasound report

2D Echo
ECG
Treatment:
Day 1
BP:120/80 mmHg
PR: 64 beats/min 
RR:18 Cycles/min
Afebrile on touch , pallor present
Tab.Atenolol 50mg+
Tab.Amlodipine 5mg
Monitoring bp 4 hourly
Day 2
BP: 130/80 mmHg
PR:70 beats/min
RR:20cycles/min
Afebrile on touch and pallor present
Tab.Atenolol 50mg+
Tab.Amlodipine 5mg
Monitoring bp 4hourly

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