A 42 YEAR OLD PATIENT WITH PALPITATIONS,SOB AND HEADACHE

 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.

15 days back he had c/o frothy urine which was  intermittent , resolved now.

No c/o chest pain/ orthopnea/syncopal attacks.

No c/o 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 along 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

Diet-mixed

Sleep-adequate

No allergies

GENERAL EXAMINATION-

Pallor - absent

Icterus- absent

Cyanosis- absent

Clubbing- absent

Pedal edema- absent

VITALS AT PRESENTATION-

BP- 180/110

PR- 120 , regular ( ECG sinus tachycardia)

SYSTEMIC EXAMINATION-

*CVS: S1S2 heard

*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