Final Practical Exam Short Case

Short case

K.Shubankar 

1701006169

 This is an 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 with an aim to solve those patient's clinical problems with collective current best evidence-based inputs. This E-logbook also reflects my patient-centered online portfolio and your valuable inputs in the comments 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.

A 25 year old female patient who is a housewife and resident of Miryalaguda came to OPD with cheif complaints of 

CHEIF COMPLAINTS:

High blood pressure ( came for checkup )

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back then she developed hypertension which was found out on her 1 St pregnancy. She had 2 abortions in the past i.e in 1 year back in 2021 and 5 months back in 2022 .Her obstetric formula is P2A2L0. 

In 1st pregnancy i.e 1 year back in 2021 when the patient conceived she visited obstetrician and found out to have hypertension which was 150/100 mmhg.She had history of pedal edema. She was started on anti hypertensive drugs i.e tablet labetalol 100 mg PO BD. At around 8 months, patient had Intrauterine death of fetus and baby was delivered by normal vaginal delivery. 

Then she stopped taking anti hypertensive drugs.After a gap of 3 months she conceived again in 2022.

In 2nd pregnancy i.e 5 months back in 2022 she conceived and found out to have hypertension which was160/100mmhg. She was started on anti hypertensive drugs i.e tablet labetalol 100mg PO BD. At around 8 months preterm delivery which was done by normal vaginal delivery, the baby died within 1 day.

Now the patient has no history of palpitations, shortness of breath, pedal edema, decreased urine output, headache, blurring of vision.

PAST HISTORY:

History of hypertension since one year

No history of Diabetes mellitus, Tuberculosis, Asthma, CAD

No history of blood transfusion

No history of previous surgeries

TREATMENT HISTORY:

History of usage of anti hypertensive drugs i.e labetalol. 

PERSONAL HISTORY:

Diet : Consume both Veg and Non-Vegetarian foods

Appetite: normal

Bowel and bladder : regular

Sleep : adequate

No addictions

No allergies

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

After taking informed consent the patient was examined in a well lit room. 

On Examination: Patient is Conscious, Coherent and Cooperative well oriented to time, place and person

Clubbing - absent

Pallor - absent

Icterus - absent

Cyanosis - absent

Edema of feet - absent

Lymphadenopathy - absent

VITALS:- 

On admission i.e on 8-6-22 :

 Temperature: afebrile

  BP: 170/100 mm hg 

  PR: 90 bpm

  RR: 22 cpm

  SPO2: 98%

  GRBS: 164 mg%

On 11-6-22:

Temperature: afebrile

BP: 160/100mmhg

 PR: 98 bpm 

 RR: 16 cpm 

 

On 12-6-22 :

 Temperature: afebrile

 BP: 120/80mmhg

 PR: 74 bpm 

 RR: 16 cpm 

 

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :

 S1 and S2 heard, no murmurs heard

 

RESPIRATORY SYSTEM :

 BAE present, NVBS heard, position of trachea - central

PER ABDOMEN : 

soft, non tender.

No organomegaly.

CNS: 

Higher mental function intact,NAD.

INVESTIGATIONS:

Blood urea : 19

Serum creatinine: 0.8

CBP

Hb: 14.1

TLC: 9,900

Neutrophils: 65

Leucocytes: 30

PCV : 40.4 

MCV: 85.4

MCHC: 34.9

Platelet count: 3.64

RBC: Normocytic normochromic

Ultrasound Abdomen

On 8-6-22:

Na - 142

K - 3.8

Chloride- 103

Complete Urine Examination:

Albumin- trace 

LFT: 

SGOT: 20

SGPT: 30

ALP: 218

Total Protein: 7.6 

Albumin: 4.18 

A/G ratio: 1.22

Thyroid Profile:

T3- 1.32

T4- 10.75

TSH- 2.32

Lipid Profile: 

Total cholesterol-204

Triglycerides-201

HDL- 55

LDL-120

VLDL-40.2

Chest X-ray:

PROVISIONAL DIAGNOSIS:

YOUNG ONSET HYPERTENSION

TREATMENT:

1) Tablet. AMLONG 5 mg PO OD 

2) Tablet. Zincovit PO OD.