Case No : 4

Preliminary Data :
Name : Mrs.Suganthi. Op.No : 59396.
Age/Sex :52 years/Female. Date : 31.07.2023.
Occupation : House Wife.
Marital status : Married.
Socio-economic status : Middle income group.
Address : Singalandhapuram.

Final Diagnosis : SYSTEMIC HYPERTENSION

Presenting Complaints :
Known Hypertension since 7 years.
History of Presenting Complaints :
Known Hypertension since 7 years.
Associated with palpitation of chest.
Modality : < over exertion, sudden emotion. > rest.
Past History :
History of Chickenpox at the age of 7 years, took native treatment and got relieved.
History of Chickungunya at the age of 51 years, took allopathic treatment and got relieved.

No history of measles, diabetes mellitus, bronchial asthma, jaundice, dengue etc..

Family History :
His mother had the history of hypertension.
No history of Asthma, Diabetes mellitus, Malignancy among family members.
Personal History :
Born and brought up : Salem.
Vaccination :Done.
Milestone : Normal.
Education: 12th standard.
Marital status: Married. Non consanginous
marriage.
Married at the age of 19 years.
Diet : Non Vegetarian.
Habits : No Habit of drinking tea or coffee.
Addictions : No Specific Addictions.
Physical Generals :
Thermal Relation : Chilly patient.
Appetite : Good & Satisfied appetite, takes 3 times/day, no nausea and vomiting.
Thirst : Quenchable thirst, drinks 3 litres/day, no dryness of mouth & throat.
Desire : Nothing specific.
Aversion : Nothing specific.
Urine : Normal micturition, passes 5 times/day, passes 1-2 times/night, no burning micturition.
Stool : Regular bowel habit,passes 1 time/day, no straining.
Sweat : Normal, only on exertion.
Sleep : Sound sleep, no Specific dreams .
Mental Generals:
Introverted.
Religious.
Wants to independent.
Obstetrical/Gynaecological History :
G2 P2 A1 L2 S0
P1 , Full term vaginal delivery.
P2 ceserean section delivery.
Attained menopause at the age of 51 years.
General Examination :
Conciousness: Patient is conscious.
Orientation: Patient is oriented to time, place, person.
Comfortable: Patient is comfortable.
Built: Obese.
Body proportion: Upper part of the body is in equal proportion to the lower part of the body.
Nutrition: Moderately nourished.
Decubitus: No specific decubitus.
Aneamia: No pallorness.
Jaundice: Not jaundiced.
Cyanosis: No cyanosis.
Clubbing: No clubbing.
Lymphadenopathy: No lymphadonopathy.
Pedal oedema: No pedal oedema.
Skin & Hair: Normal textured hair.
No dryness of skin.
Weight : 92 kg.
Height : 158 cm.
Vital signs:
Pulse :Rate :72 /minute.
Rhythm : Regular .
Volume : Normal volume pulse.
Character : Tidal wave elicited.
Vessel wall thickening : No vessel wall thickening.
Blood pressure : 160/100 mmHg.
Respiratory rate : 19/minute.
Temperature : 98.6°F.
Systemic Examination :
Cardiovascular system :
Inspection :
No Pre cordial bulge
Normal tracheal position.
No engorged veins seen.
No Parasternal heave or lift.
No visible pulsation.
No scarmarks.
No visible necks veins seen.
Apical impulse not seen.

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.
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 Atrial fibrillation.

o Hyper thyroidism.

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 :

SACCHARUM LACTIS /1 dose (1-0-0) Before food.

RAUWOLFIA SERPENTINA Q / 30 ml ( 15°-0-15° ), After food
X 1 Month

Follow up :
14.8.2023
Patient feels better.
Palpitation of chest reduced slightly.
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 : 68/minute.
Blood pressure : 140/80 mmHg.

SACCHARUM LACTIS /15 dose ( 1-0-0) Before food.

RAUWOLFIA SERPENTINA Q / 15 ml ( 0°-0-15° ), After food
X 2 Weeks.
28.8.2023
Patient feels better,
Palpitation of chest reduced 40%.
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 : 67/minute..
Blood pressure : 120/80 mmHg.

SACCHARUM LACTIS /15 dose ( 1-0-0) Before food.

RAUWOLFIA SERPENTINA Q / 30 ml ( 0°-0-15° ), After food.
X 2 Weeks.

12.09.2023
Patient feels better.
Palpitation of chest reduced . 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 : 71/minute.
Blood pressure : 110/ 70 mmHg.

SACCHARUM LACTIS/ 7 dose ( 1-0-0) Before food.

RAUWOLFIA SERPENTINA Q / 30 ml ( 0°-0-15° ) After food.
X 2 Weeks.