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Preliminary Data :
Name : Mr.Chinnadurai. Op.No : 58881
Age/Sex : 53 years/ Male. Date : 01.06.2023
Occupation : Bus Driver.
Marital status : Married.
Socio-economic status : Middle income group.
Address : Namakkal.
Presenting Complaints :
Known Hypertension since 3 years.
Past History :
History of Renal calculi at the age of 35 years, took allopathic treatment & got relieved.
Palpation :
No tenderness.
No warmthness.
No organomegaly.
Auscultation :
Aortic area - S1 & S2 heard normally in aortic area.
Pulmonary area- S1 & S2 heard normally in pulmonary area.
Mitral area - S1 & S2 heard normally in mitral area.
Tricuspid area - S1 & S2 heard normally in tricuspid area.
Respiratory system :
Chest bilaterally symmetrical.
No scar mark.
No muscle wasting.
No dilated vein.
Normal vesicular breath sound heard all over the lung field, no added sounds heard.
Gastrointestinal system :
Scaphoid shaped abdomen.
No tenderness.
No organomegaly.
No distension of abdomen.
No dilated veins.
No scar mark.
Genito Urinary System :
No inflammatory signs.
No visible swelling.
No abnormal discharge.
No scar marks.
Central Nervous system:
No focal neurological deficit.
12 cranial nerves are normal.
Higher functions are normal.
Both motor & sensory functions are
normal.
Locomotor system :
Normal gait.
No deformity.
No restricted
movement.
Provisional Diagnosis :
? Systemic Hypertension .
Differential Diagnosis :
o Benign paroxysmal positional vertigo.
o Meniere's disease .
Lab Diagnosis:
Adviced to take Electrocardiogarm
Final Diagnosis :
SYSTEMIC HYPERTENSION
General management :
o Advice to do yoga and exercise.
o Advice to avoid alcohol drinking, salt rich foods.
o Advice to take nutritious food and rest.
First Prescription :
Follow up :
20.06.2023
Patient feels better.
Giddiness reduced upto 10%.
No new complaints.
Physical Generals :
Appetite : Good & Satisfied, takes 3 times/day, no nausea and vomiting.
Thirst : Quenchable thirst, no dryness of mouth & throat.
Urine : Normal micturition, no burning.
Stool : Regular bowel habit, no straining.
Sleep : Sound sleep, no Specific dreams.
Vital signs :
Pulse : 78/minute.
Blood pressure : 130/90 mmHg.
19.8.2023
Patient feels better.
Giddiness reduced upto 50%.
No new complaints.
Physical Generals :
Appetite : Good & Satisfied, takes 3 times/day, no nausea and vomiting.
Thirst : Quenchable thirst, no dryness of mouth & throat.
Urine : Normal micturition, no burning.
Stool : Regular bowel habit, no straining.
Sleep : Sound sleep, no Specific dreams.
Vital signs :
Pulse : 64/minute.
Blood pressure : 120/80 mmHg.