A 42 YEAR OLD PATIENT WITH PALPITATIONS, SOB AND HEADACHE

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 A 42 year old male patient came with the c/o palpitations since  morning , difficulty in breathing since morning, Headache since morning ,Frothy urine 15-20 days ago (not present now)

HISTORY OF PRESENTING ILLNESS-

Pt was apparently alright till morning when he had c/o palpitations a/w SOB grade II. He also had complaints of headache which is diffuse a/w nausea not a/w lacrimation/photophobia/phenophobia

Since 15 days he has c/o frothy urine which was  intermittent , resolved now

No c/o chest pain/ orthopnea/syncopal attacks

No c/0 pain abdomen, loose stools, fever, constipation,burning micturition, vomitings

No c/o tingling/ paresthesis/ involuntary movements 

No c/o neck pain, giddiness 

PAST HISTORY-

H/o similar complaints in the past apong with chest pain , pain abdomen and malena 1 year back diagnosed with uncontrolled hypertension and AKI on CKD and was given medication which he used for 3 months and then stopped

ADDICTIONS:

Alcohol:since 20 yrs 2/3 times per week (5/6 units)

PERSONAL HISTORY: 

Appetite -normal

Bowel and bladder movements:normal

No allergies

GENERAL EXAMINATION-

Pallor - ab

Icterus- ab

Cyanosis- ab

Clubbing- ab

Pedal edema- ab

VITALS AT PRESENTATION:

Bp- 180/110

Pr- 120 , regular ( ECG sinus tachycardia)

SYSTEMIC EXAMINATION-

CVS: S1S2

RESPIRATORY SYSTEM:BLAE+

ABDOMINAL EXAMINATION:SOFT,NT,bowel sounds+

CNS:NFND

INVESTIGATIONS-





PROVISIONAL DIAGNOSIS-

Hypertension urgency

K/c/o hypertension since 1 year, drug defaulter

TREATMENT-

1)TAB. CINOD-T PO/OD

2))TAB. MET -XL 25mG PO/OD

3)TAB ZOFER 4mg PO / SOS

4)TAB ATROVAS 20mg PO/OD/HS

5) BP/ PR / RR / temp monitoring hourly

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