159 Ravali Irugurala
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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