A 70 year old with hypertension

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



I have 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 diagnosis and treatment plan.



A 70 year old male came with chief complaints of denovo hypertension.


History of presenting illness:


Patient was apparently asymptomatic 1 month back then he developed watering of left eye and blurring of vision.

Yesterday he went to govt hospital to check for his eye symptoms then he was told that he had high BP of 190/100 mm hg.Then he came to our hospital for evaluation.

 No H/O palpitations 

No h/o chestpain, shortness of breath

No h/o headache,sweating,burning micturation

No h/o weight loss.

He gave history of loss of appetite since 2 months



Daily Routine 


Patient gets up early in the morning at 4:00 am and get ready to go for his tea stall at 4:30 am.He works there till 10:00am and come back to home and have his breakfast at 10:30 am . He usually eats rice in the morning .The whole day he is at home and have his dinner at 8:30 pm. He skips his lunch due to his loss of appetite.He sleeps around 9:00pm.



Past history:


40 years back  he had an accident where his leg got fractured. He got admitted in the hospital and had a cast but he took some ayurvedic medine to heal the fracture.


https://youtube.com/shorts/wLc7zDiH3c8?feature=share

3 years back he got admitted in the hospital for jaundice with fever



Personal history 


Diet: mixed

Sleep:disturbed sleep due nocturia ( nearly 5 times)since 1 year

Bowel : normal

Bladder: frequent urination in the night

Addictions: no addictions

No allergies


General examination 


Patient is conscious,coherent,cooperative ,well oriented to time, place and person.


Pallor: absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy:absent

Pedal edema: present ( pitting type)

BP:130/90 mm hg

PR:70bpm

Temp: afebrile

RR: 16cpm











Systemic examination 


CVS - S1 S2 heard

R/S - inspection shape - scaphoid 

No scars present

Trachea- central

Auscultation:

Vesicular breath sounds heard

P/A - 

Inspection - obese abdomen, Umbilicus inverted , No abdominal distention,scars and swelling.

PALPATION:   Soft, non tender, no organo megaly.

AUSCULTATION:

BOWEL SOUNDS HEARD

CNS - NO focal deficit found.

On eye examination: bilateral immature cataract is present.


Diagnosis

Denovo hypertension 


Investigation 


Serum creatine:1.1

Sodium:136    Normal(136-145)

Potassium:4.4.  Normal(3.5-5.1)

Chloride :102.  Normal(98-107)

Direct bilirubin:0.01.    Normal(0.0-0.2)

AST:19.   Normal(0-35)

ALT:14.  Normal(0-45)

ALP:78.   Normal(56-119)

Total protein:8.2.  Normal(6.4-8.3)







Treatment 

NICARDIA 10 mg







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