case history of an primary hypertention patient

1. MEDICAL CASE HISTORY OF A PATIENT
BIODATA
CASE NO:- 231
NAME:-S SIVA KUMAR AGE:-45years
SEX:- MALE REGION:-INDIA
RELIGION:-INDIAN INSURANCE:- NO
GARDIAN NAME:- KUMARI SUHANA
GARDIAN PH NO:-9581836463
ADRESS:- HNO-1-111,
NAHRUSTREET,
MADANAPALLI.
ADMISSION DETAILS
DATE:-26/2/2018 DAY:-monday
TIME:-8;30PM ADMITTEDBY:-neighbour
COMPLIENTS OF PATIENT BY GARDIAN:-
 Shortness of breath.
 full cough and cold.
 Chest pain.
 Raising in heart beat.
 Legs and feet pains.
 Rashes on legs.

2. HISTORY OF PRESENT ILLNESS
 high fever dint stoped my medications.
 Patient struggling at every breath.
 Can’t breath properly.
 Coughing with green thick phylem.
PAST MEDICAL HISTORY:-
 Patient post hiv infected.
 4months back is diagnosed with malariya.
 Frequenty getting respiratory distress with cough.
FAMILY HISTORY
Patient married 5years ago,after marrage he know he had hiv
positive, he has more sexuval parteners before marrage.
SOCIAL HISTORY:-
Patient is vegetarion.
He worked at taning industry since 7 years.
ALLERGIES:-
He is allergic for diclofenacim injection.
Allergic to pencillin.
MEDICATION HISTORY:-
 Patient taking anti viral drug (abacavir).
 Previsously used antibiotics.
 Using reverse transe criptase inhibitertherapy.

3. PHYSICAL EXAMINATION:-
Temperature:-99°f BP:-180/85
Weight:-70kgs height:-6 feet
Pulse:-85B/min
Aappearence: - lean in body weight decreased.
Cyanoticface and legs,
Eyes red and lacrimationoccure,
Cough with poorphlegm,
Feet swelling,
Forced breathing,ortopneaposition.
Percussion:-
Lungs:-normal sound(clear)
Heart:-normal sounds(dull)
Kidneys:-normal(dull)
Palpation:-
Lungs:-normal
Heart:-normal
Kidneys:-increased size.(hepatomegaly)
Venus palpation:-jugularvenous palsationincreased

4. Auscultation:-
Lungs:-wekaning of vesicularbreath,pluralrub.
Heart:-normal.
6min walk test:- less than 55mm hg.
LAB INVESTIGATION:-
COMPLETE BLOOD COUNT:- normal observed
RBC{ERETROCYTES} 4.6-6.4mil/cu 4.5mil/cu
HB% 10mg/ml 11mg/ml
Mean corpucellsvol{MCV} 78-97fl/ml 100fl/ml
Leucocytes 4000-11000mm/cu 55000mm
differential wbc count:-
 Neutrophils 60-75% 100%
 Lymphocytes 20-30 % 26%
 Monocytes 2-8 % 8%
 Eosinophils 1-6 % 80%
 Basophils 0-4 % 2%
Platelets 150000-250000 cl/mm 156000cl/mm
COOMBS TEST:- POSITIVE

5. INSTRUMENTATION:-
Phonocardiogram:-
4th
left intercoastal space shows murmur of tricuspid
insufficiency.
x-ray of lungs:-
pruning of blood vessels in middle.
ECG:-
lead 2 peak P wave seen.
V1 large V wave.
Eco cardiogram:-
in plex view left ventricles dilated,Pulmonaryartery
dilated.
apicalview dilatedRV,RV hypertrophy.
In short axis RV hypertrophy,smallleft ventricle.
Right lung cathetarisation:-
35 mmhg at sleep
45 mmhg at physicalactivity.
diagnosised as:-pulmonary hypertention
group 1.

6. refered by:-
drpavan kumar,
CASS medical hospital,kalikiri.