40 M C/o weaknesses of body since 1 month

12/05/2023

40 yr male Pt came to the opd with C/o weakness of the body since 1 month

Hopi : pt was apparently asymptomatic 4 yrs back then he developed headache and weakness of body . So , he went to the local doctor and was diagnosed as hypertension. But patient was not taking any medication. So, he again developed weakness of the body since 1 month .

Weakness is associated with the the dizziness and sweating .

No H/0 nausea , vomiting , burning micturition, constipation .

Past H/o : k/C/o HTN since 4yrs but not taking any medication

N/k/C/O DM , Asthama , TB , epilepsy, cva , cad ,thyroid.

General examination: pt. Was conscious, coherent and cooperative moderately built and well nourished.

General examination;

No pallor , icterus,cyanosis, clubbing,pedal edema , no lymphadenopathy

Vitals

Temp- afebrile

PR - 90 bpm

BP- 170/100mmHg

RR- 16CPM

Systemic examination

CVS- S1,S2 heard,no murmurs

RS - BLAE, NVBS

Per abdomen - Tenderness present in the epigastric region and left lumbar region

CNS : NFND

Treatment: pt. Was advised to take home bp monitoring machine.

Initially pt was advised to take Telmisartan 40 mg but his bp readings did not improve . So , we advised patient to take telmisartan 80 mg . Still his bp readings did not improved .

So, we added amlodipine 5 mg then his bp readings were improved and we asked the patient to continue amlodipine 5mg