Case No : 3

Preliminary Data :
Name : Mrs. Amutha. Op.No : 59725
Age/Sex :47 years/Female. Date : 21.8.2023
Occupation : House Wife.
Marital status : Married.
Socio-economic status : Middle income group.
Address : Perambalur.

Final Diagnosis : SYSTEMIC HYPERTENSION

Presenting Complaints :
Giddiness and palpitation since 7 years.
History of Presenting Complaints :
Giddiness and palpitation since 7 years.
Modality : < over exertion > rest.
Associated with tiredness of the body.

Past History :

History of Mumps at the age of 25 years, took native treatment & got relieved.

No history of measles, diabetes mellitus, bronchial asthma, jaundice, chikungunya,

dengue etc..
Family History :
No history of Bronchial asthma, Tuberculosis, Malignancy among family members.
Personal History :
Born and brought up : Atthur.
Vaccination :Done.
Milestone : Normal.
Education: 5th standard.
Marital status: Married. Non consanginous
marriage.
Married at the age of 18 years.
Diet : Non Vegetarian.
Habits : Habit of drinking tea occassionally.
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 : Increased sweat. Offensiveness present.
Sleep : Sound sleep, no Specific dreams .
Mental Generals:
Easily mingled with others.
Locauqious.
Obstetrical/Gynaecological History :
G3 P3 A0 L3 S0
P1, P2 , P3 Full term vaginal delivery .
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: 94.6 kg.
Height: 153 cm.
Vital signs:
Pulse :Rate :76 /minute.
Rhythm : Regular..
Volume : Normal volume pulse.
Character : Tidal Wave elicited.
Vessel wall thickening : No vessel wall thickening.
Blood pressure : 190/110 mmHg.
Respiratory rate : 17/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 Benign paroxysmal positional vertigo.

o Meniere's disease .
o Atrial fibrillation.
o Hyperthyroidism.
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 :

LACHESIS 200 /1 dose (1-0-0) Stat.

RAUWOLFIA SERPENTINA Q / 15 ml ( 10°-0-10° ), After food.
X 2 weeks
Follow up :
02.09.2023
Patient feels better.
Giddiness and palpitation reduced slightly.
No new complaints.
Physical Generals :
Appetite : Good & Satisfied, takes 3 times/day, no nausea and vomiting.
Thirst : Quenchable thirst, no dryness ofmouth & throat.
Urine : Normal micturition, no burning.
Stool : Regular bowel habit, no straining.
Sleep : Sound sleep, no Specific dreams .
Vital signs :
Pulse : 76/minute.
Blood pressure : 170/100 mmHg.

SACCHARUM LACTIS /4 dose ( 1-0-0) weekly once Before food.

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

19.9.2023
Patient feels better.
Giddiness and palpitation reduced 50%.
No new complaints.
Physical Generals :
 Appetite : Good & Satisfied, takes 3 times/day, no nausea and vomiting.
Thirst : Quenchable thirst, no dryness ofmouth & throat.
Urine : Normal micturition, no burning.
Stool : Regular bowel habit, no straining.
Sleep : Sound sleep, no Specific dreams.

Vital signs :
Pulse : 75/minute.
Blood pressure : 140/90 mmHg.

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

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