57 year old female with throat pain

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. 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








TREATMENT:-

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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