159 Ravali Irugurala

General medicine

68 yr old female with HTN

This is an online E logbook 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 an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. 

This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are 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 diagnosis and treatment plan.

Following is the view of my case :

Date of admission: 16/11/22

Case presentation

Chief complaints:

Patient came to the casuality with high blood pressure recordings 200/100 MMHG

HOPI:

Patient was  apparently asymptomatic 4 years back and then she developed chest pain for which she diagnosed with anterior wall MI for which PTCA with stenting done in 2019.

On 16/11/22 when patient is on regular medical checkup found have high blood pressure recordings and patient was admitted for the above mentioned complaints 

Past History:

K/c/o Hypertension since 15 years and on medication

K/c/o Hypothyroidism since 10 years and on medication

Not a k/c/o Diabetes, TB, asthama, epilepsy, CAD,CVA 

Personal history:

Diet - mixed 

Appetite - normal

sleep - adequate

Bowel and Bladder movements -regular

Addictions - no

No known allergies

DRUG history:

TAB: TELMA-H 40 mg PO/OD

TAB: THYRONORM  MCG PO/OD

General examination:

Patient is conscious,coherent,cooperative and was well oriented to time ,place and person at the time of examination.

He is well nourished and moderately bulit

Pallor - mild

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

VITALS: on  the day of admission 

Pulse rate - 52Bpm

Respiratory rate - 14 cpm

Blood pressure - 200/100mmhg

Temperature - Afebrile 

Systemic Examination:

CVS : S1 and S2 heart sounds hear

NO murmurs and thrill

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard

CNS : no focal deficits found

ABDOMEN :

Soft

Non tender

No palpable mass

 Bowel sounds heard

 NO organomegaly

Provisional diagnosis:

Hypertensive urgency 















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