57 year old female with throat pain
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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. 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.
A 57 years female patient resident of marpaka village daily worker by occupation came to ent opd with
chief complaints of throat pain since 7 days
History of present illness:-
Patient was apparently asymptomatic 5yrs back then she developed lower back pain which is non radiating , for which she went to local hospital and she said that she had some kidney problem and not completely resolved as she stopped medication after 2 months.
In October 2022- History of bilateral lower limb swelling present upto ankle and facial puffiness was noted.
Then the attenders took her to hospital at Nalgonda where she underwent 2 episodes of dialysis.
History of throat pain since 7 days .On examination her blood pressure was recorded 190/110 soon she was referred to general medicine opd.
No history of fever, headache.
No history of blurring of vision
PAST HISTORY:-
She is a known case of hypertension since 3 yrs.
No history of Asthma , Tuberculosis,Diabetes mellitus, epilepsy.
PERSONAL HISTORY:-
Appetite-normal
Diet - Mixed
Sleep - adequate
Bowel and bladder - Regular
Addictions - No addictions
FAMILY HISTORY:-
Not significant
SURGICAL HISTORY:-
History of hysterectomy 10 years back
TREATMENT HISTORY:-
For hypertension since 3 years.(Medication-unknown)
GENERAL EXAMINATION:-
Patients is conscious, coherent and cooperative.Well oriented to time, place,person.
Pallor-Absent
Icterus-Absent
Cyanosis-Absent
Clubbing-Absent
Lymphadenopathy-Absent
Edema-pitting type of edema present
VITALS:-
Temperature:-Afebrile
Pulse rate:-86bpm
Respiration:-17cpm
Blood pressure:-160/90 mmHg
SYSTEMIC EXAMINATION:-
CNS-No focal neurological deficits
CVS-on inspection
Ascultations
S1 & S2 heard.No murmurs
Rhythm regular
Jvp-not seen
Palpations-
Apex beat at 5th intercostal space
Respiratory system -Bilateral air entry present.
Per Abdomen -Soft and non tender.
Tendernesses-no
Free fluid-no
Spleen not palpable
PROVISIONAL DIAGNOSIS:-
Hypertensive urgency
INVESTIGATIONS:-
Fundus examination - Normal
3/12/2022
4/12/2022
3/12/2022
Tab.Nicardipine 20 mg PO
Monitor vitals
4/12/2022
-Fluid restriction
-Salt restriction
-Tab.Shelcal 500 once daily
-Tab.Lasix 40mg PO once daily
-Tab.Clinidipine 10mg PO once daily
-Monitor vitals
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