Case history 3
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Date of examination: 21/9/2021.
A 35yrs female came to OPD with Chief complaint of blood pressure since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 weeks ago, then she got fever 10 days ago, fever subsided after taking medication for 3 days. Then she was diagnosed as HTN. She is presently on medication for HTN since 19/9/2021.
HISTORY OF PAST ILLNESS:
No evidence of target organ damage.
No history of burning vision, angina, reduced urine output.
She had 2 pregnancies:
1st pregnancy: in 8th month she had high blood pressure, on medication HTN subsided and normal delivery was done.
2nd pregnancy: in 8th month she had HTN on medication it subsided and C -section was done.
No history of diabetes, thyroid, epilepsy, TB.
FAMILY HISTORY:
No history of diabetes, stroke, asthma, heart disease, cancer, tuberculosis.
Hypertension : yes (father).
PERSONAL HISTORY:
Appetite: normal.
Sleep: adequate
Diet: mixed.
Normal bowel and bladder movement.
No addictions.
Menstruation: normal.
GENERAL EXAMINATION:
No history of lymphadenopathy, icterus, clubbing of fingers, cyanosis, edema of feet, malnutrition.
Temperature: Afebrile
Pulse rate: 80 beats/min
Respiratory rate: 20 cycles/min.
BP : 170/110 mm Hg.
SPO2: 98%.
INVESTIGATIONS:
HAEMOGLOBIN: 10.7 gm/ dl
Total count:36000
Lymphocytes:45%.
PCV: 32.3 vol%
MCV:68.3fl
ECG:
TPR GRAPHIC SHEET:
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