32 year old with chronic uncontrolled hypertension

 

32 year old with chronic uncontrolled hypertension

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's 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. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

FOLLOWING IS THE VIEW OF MY CASE

CHIEF COMPLAINTS

C/O right side neck pain since 4 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2yrs back

 

- he had food poisoning for which he visited local practitioner where on regular vitals examination, he was found to have high BP (230/?) and he was given nifedipine 10mg stat & for 2 more days after which BP returned to be normal 

- with neck pain he went to local hospital where 240/140mmhg BP is noted and was given nifedipine 10mg

 (I) neck pain - dragging type 

 (II) associated with blurring of eyes, palpitations, sweating 

(III)  pain reliefs on applying balm 

(IV) no aggravating factors 

PAST HISTORY 

not a known case of DM, TB,CVD, thyroid disorders epilepsy

H/O surgery for renal calculi 2 times ( 6 years and 3 years back) 

PERSONAL HISTORY :

1. Diet: mixed
2. Appetite: increased
3. Bowel habits: normal
4. Bladder habits: normal
5. Sleep: normal
6. Addictions:    Occasional alcohol consumption 

      Whisky/ beer (4beers)               

Daily routine 

6am - wake up 

9am-9:30am - breakfast ( Upma, chapathi etc)

1:30pm-3pmlunch ( rice and curry)

9pm - dinner ( chapathi, upma etc)          

                            

                             

FAMILY HISTORY :

Mother is hypertensive since 10years

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

• Pallor          - absent
• Icterus        - absent
• Clubbing    -absent
• Lymphadenopathy    - absent
• Cyanosis     - absent
• Pedal edema  -absent

VITALS :

• Temperature - 98.6 F
• Pulse : 96 bpm 
• Respiratory rate : 28 per minute 
• Bp 190/110 mmHg
• Spo2 98%
• GRBS 122 mg%

CVS EXAMINATION 

 S1 S2 heard

no murmurs

RESPIRATORY SYSTEM

Bilateral air entrty present

NVBS

PER ABDOMEN 

soft, non tender

CNS EXAMINATION : 

No focal neurological deficits

INVESTIGATIONS