A 60 year old male came with severe head ache





 


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 60 year old came to opd with severe headache


Chief complaints 

Severe headache since 5 days


Hopi

Patient was apparently asymptomatic 5 days back then he developed headache , so he visited local RMP and diagnosed with hypertension ( 160/100) then he had local medicines. The next day BP was high so he was asked to refer to higher centre.yesterday his BP was 200/110 when he came to our hospital.

Neck movements are restricted since 5 days

No h/o fever

No h/o vomitings 


Past history 

No h/o DM,CAD, epilepsy,thyroid,asthma,TB

History of fracture to right arm


Daily routine

 Patient gets up at 4 am and does he daily chores ,have breakfast at 9 am (rice , vegetable curry,tea) and goes to his daily labour work.he ll have his lunch at work and comes back to home at 5pm .he ll have alcohol(. 90ml)daily night and have his dinner at 9pm and sleeps at 10pm.


Personal history 

Appetite: normal

Diet:mixed

Bowel: normal 

Bladder:decreased frequency 

Addictions: alcohol and beedi(daily 5 )



General examination 


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





Video of restricted neck movement 

https://youtube.com/shorts/Alw-93VZ9G8?feature=share


Pallor: absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy:absent

Pedal edema: absent


Vitals

BP: 180/100

PR:70bpm

Temp: afebrile

RR: 16



Systemic examination 


CVS - S1 S2 heard

R/S - inspection

No scars present

Trachea- central

Auscultation:

Vesicular breath sounds heard

P/A - 

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

PALPATION:   Soft, non tender, no organo megaly.

AUSCULTATION:

BOWEL SOUNDS HEARD

CNS - NO focal deficit found.

No meningeal signs 


Investigations




   USG


Provisional diagnosis


Hypertensive urgency

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