a 50 year old female with c/o dry cough and giddiness

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient' problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

a 50 year old female with chief complaints :
-Dry cough since 3days
-Giddiness and palpitations since 7/8/22 evening. 

HOPI :
Patient was asymptomatic 5years back and then developed high grade fever and associated with chills for which she went to hospital and was treated conservatively and also had giddiness at that time for which she was known yo be having htn and using medication. since then asymptomatic till 7/8/22 evening 5pm and developed giddiness and palpitation. 
k/c/o HTN 
n/k/c/o DM,ASTHMA,CAD AND TB

Personal history :
occupation - farmer.
appetite - normal
bowel - regular
micturition - normal

- Occasionally toddy drinker since 20years
- Betel leaf since 20years


On Examination :
BP - 190/80 mm/hg
RR - 14 CPM
SPo2 - 98%
GRBS - 106 mg
Pulse - 96 bpm
Temp - 98.6 F

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema of feet and dehydration.

Provisional diagnosis : HTN URGENCY

On 7/8/22
Tab.amlong 5mg PO/OD
Tab.nicardia 10mg stat
Tab.vertin 16mg PO/BD
BP charting (2nd hourly)

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