Case No : 1

Preliminary Data :
Name : Mrs.Sirajnisha Op.No : 57380
Age/Sex : 55 years/Female. Date : 27.04.2023
Occupation : Cook.
Marital status : Married.
Socio-economic status : Middle income group.
Address : Salem.

Final Diagnosis : SYSTEMIC HYPERTENSION

Presenting Complaints :
Giddiness since 5 years on & off.

History of Presenting Complaints :

Giddiness since 5 years on & off.
Onset : Gradual.
Sensation : Tendency to fall forward.
Modality : < over exertion > rest.
Associated with tiredness of the body.
Known hypertension for 25 years and taking allopathic treatment and not relieved.

Past History :

History of Dengue fever at the age of 52 years, took allopathic treatment & got relieved.

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

tuberculosis etc..
Family History :
No history of Bronchial asthma, Tuberculosis, Malignancy among family members.
Personal History :
Born and brought up : Salem.
Vaccination :Done.
Milestone : Normal.
Education: 5th standard.
Marital status: Married. Non consanginous
marriage.
 Married at the age of 20 years.
Diet : Non Vegetarian.
Habits : Habit of drinking tea 3times/day.
Addictions : No Specific Addictions.
Physical Generals :
Thermal Relation : Chilly patient.
Appetite : Increased appetite, takes 4-5 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.
Worried about her children’s future.
Gets anger easily and breaks things in the anger.
Obstetrical/Gynaecological History :
G2 P2 A0 L2 S0
P1 & P2 Full term normal vaginal delivery .
Attained menopause at 49 years.
General Examination :
Conciousness: Patient is conscious.
Orientation: Patient is oriented to time, place, person.
Comfortable: Patient is comfortable.
Built: Well built.
Body proportion: Upper part of the body is in equal proportion to the lower part of the body.
Nutrition: Well 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: 64 kg.
Height: 153 cm.

Vital signs:
Pulse :Rate :78 /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/minutes.
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.
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 :

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

RAUWOLFIA SERPENTINA Q / 30 ml ( 10°-0-10° ), After food.
X 2 weeks

Follow up :
25.05.2023
Patient feels better.
Giddiness reduced upto 10%.
Tiredness of the body reduced upto 30%.
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 : 72/minute.
Blood pressure : 150/100 mmHg.

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

RAUWOLFIA SERPENTINA Q / 30 ml ( 10°-0-10° ), After food
 X 2 weeks.

22.6.2023
Patient feels better.
Giddiness reduced upto 30%.
Tiredness of the body 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 : 75/minute.
Blood pressure : 130/90 mmHg.

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

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

22.6.2023
Patient feels better.
Giddiness reduced upto 50%.
Tiredness of the body reduced upto 80%.
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 : 75/minute.
Blood pressure : 130/90 mmHg.

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

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