This is an a 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.
CASE PRESENTATION
A 63 year old female resident of Nalgonda came to the general medicine OPD with the chief complaints of
•bilateral bilateral legs swelling since 10 days
HISTORY OF PRESENTING ILLNESS
patient was apparently asymptomatic 10days ago and then she developed bilateral leg swelling which is insidious in onset,gradually progressive, pitting type which is extending upto the knee(grade 2) associated with itching.
No aggravating and relieving factors.
History of nocturia (3-4times),snoring.
Not associated with abdominal distension, shortness of breath,cough,palpitations,chest pain,
No history of headache, blurring of vision.
hyperpigmentation of knuckles
PAST HISTORY
•she is known case of hypertension since 10 years (under medication Telma H)
•Diabetes mellitus since 10 years (under medication Metformin 500mg OD)
•History of humerus fracture 2 years ago which is treated conservatively (because of fall from steps)
•History of psoriasis 6 years ago (she had 3 lesions on scalp) used medication.
PERSONAL HISTORY
Diet- mixed
Appetite-normal
Sleep- adequate
Bowel movements-regular
No addictions
DAILY ROUTINE
she wakes up at 8 AM everyday and do her everyday rituals then she would have her breakfast at 10 AM.
She will not do regular household works(her maid will do).
She passes her day by running kiranam store.She takes her lunch at 1PM followed by short nap of 1hour,dinner at 8 PM and goes to sleep at 10 PM.
FAMILY HISTORY
her husband is also known case of hypertension and diabetes mellitus.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative well oriented to time, place and person. She is obese and moderately nourished.
Bull neck
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy.
VITALS
Temperature - 98.4°F
BP - 210/120mm of Hg
Pulse rate - 88bpm
Respiratory rate -18 cpm
GENERAL EXAMINATION
CVS
INSPECTION
Shape of chest- bilaterally symmetrical
Trachea - central
No visible pulsations
No scars,sinuses or dilated veins
PALPATION
No thrills,parastrenal heaves
AUSCULTATION
s1,s2 are heard
No murmurs
No raised jvp.
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular breath sounds are heard
PER ABDOMEN
soft,non tender,no organomegaly
CNS
No focal neurological deficit
INVESTIGATIONS
CBP
Uric acid- 7.9mg/dl
Blood urea - 39mg/dl
Serum creatinine- 0.7mg/dl
RBS- 178mg/dl
ECG
DIAGNOSIS
Hypertensive urgency?
Hypertensive crisis?
Metabolic syndrome?
TREATMENT
At 11:35 AM in OP NICARDIA 20mg was given
After 30 minutes BP was recorded-170/130 mm of Hg
After sometime it was again 210/120mm of Hg
After admitting in the ICU
LABETOLOL IV was given
SOAP Notes:
ICU
Day -2
S
Stools not yet passed
No Fever spikes
No head ache
O
Pt is Conscious, coherent, cooperative
Temp: 98.6 F
BP: 160 /100 mmHg
PR : 95bpm
RR : 14cpm
CVS : S1 S2 +
RS : BAE +
CNS :NAD ,HMF+
P/A : Soft and non tender
A
HYPERTENSIVE URGENCY
? Hypertensive Crisis
? severe uncontrolled hypertensio
P
1) inj . labetalol 20 mg IV /SOS
if SBP > 160 mmHg
2) T. Telma H PO/OD
3) T. Cinod 10mg PO/BD
4) Hourly BP monitoring
5) T. Metformin 500mg PO/OD
6) vitals monitoring 4th hourly
ICU
DAY3
S
Stools passed
No fever spikes
no headache
O
Pt is c/c/c
Afebrile
PR 96 bpm
BP 150/90
CVS: s1 s2 +
RS: BAE + , NVBS
P/A: obese , soft , NT
CNS: NFND
Grbs: 210 mg/ dl @8 am
A:
HYPERTENSIVE URGENCY WITH UNCONTROLLED HYPERTENSION
TREATMENT
1) inj . labetalol 20 mg IV /SOS
if SBP > 160 mmHg
2) T. Telma H PO/OD
3) T. Cinod 10mg PO/BD
4) Hourly BP monitoring
5) T. Metformin 500mg PO/OD
6) vitals monitoring 4th hourly
7) Tab. MINIPRESS XL PO/OD
8) MET XI 50mg PO/OD
9) GRBS 6th hourly
DISSCUSSION
relationship between OSA and hypertension
https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.106.076190
Comments
Post a Comment