32 year old with Chronic Uncontrolled Hypertension

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


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
















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