57 YEAR OLD FEMALE WITH THROAT PAIN
This is an online E log book 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 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 log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.
CASE:
57 year old female came to OPD with complaints of
Throat pain since 1 week
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 5years ago,later she developed pain in the lower abdomen,non radiating pain for which she went to nearby hospital in nalgonda and was suggested to have a renal problem for which medications were prescribed and she used the medication for 2months and stopped using the medication.
2 MONTHS AGO:-she developed bilateral lower limb swelling,pitting type and shortness of breath for which she went to hospital in nalgonda where she was said to develop severe acidosis for which she underwent 2episodes of dialysis.
7 DAYS AGO:she complained of throat pain for which she visited ENT OPD and under general examination they noticed the BP to be around 220/110mm HG.She was later referred to General medicine department for further evaluation.
5/12/2022:she complained of HEADACHE in the frontal region,NECK PAIN.
No history of fever,giddiness,blurring of vision,chest pain,palpitations,vomitings.
DAILY ROUTINE:she wakes up at 7:00AM and completed her routine activities.Takes her breakfast at 8:00am which comprises of Tea and tiffins like Idly,upma.Later,she takes her medication.She is a housewife.she does house holdworks.She takes her lunch at 1:00pm and takes a nap for 2hrs.In the evening she drinks 1cup of tea and watches television.She takes her dinner at 8:00pm which comprises of Rice with Dal,goes to sleep at 10:00pm.
PAST HISTORY:-
she is a known of case of HYPERTENSION since 3years for which she takes TAB.CLINIDINE 10mg
No history of DIABETES MELLITUS ,ASTHMA,EPILEPSY, TUBERCULOSIS.
She underwent HYSTERECTOMY 10 years ago.
PERSONAL HISTORY:-
Appetite-normal
Diet - Mixed
Sleep - adequate
Bowel and bladder - Regular
Addictions - No addictions
Allergy-No allergy
FAMILY HISTORY:-
Not significant
TREATMENT HISTORY:-
TAB.CLINIDINE 10mg OD for HYPERTENSION
GENERAL EXAMINATION:-
Patient is conscious, coherent and cooperative,Well oriented to time, place,person.
Moderately built and nourished.
Pallor-Absent
Icterus-Absent
Cyanosis-Absent
Clubbing-Absent
Lymphadenopathy-Absent
Edema-pitting type of edema present
VITALS:-
Temperature:-Afebrile
Pulse rate:-86bpm,normal rhythm,normal volume,No radio-femoral delay.
Respiration:-17cpm
Blood pressure:-160/90 mmHg
SYSTEMIC EXAMINATION:-
CVS EXAMINATION:
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
On auscultation ‐ S1, S2 heard , no murmurs
RESPIRATORY EXAMINATION:
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion:
all lung areas were resonant
On auscultation :
• Bilateral air entry was present, normal vesicular breath sounds were heard.
• Vocal resonance: resonant in all areas
ABDOMINAL EXAMINATION:
soft, non tender, no liver and spleen enlargement,no distension, bowel sounds heard.
CNS EXAMINATION:
patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal .
. Reflexes are normal .
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
No cerebellar signs.
No meningeal signs.
PROVISIONAL DIAGNOSIS:
HYPERTENSIVE URGENCY WITH CKD
INVESTIGATIONS:-
HAEMOGRAM:
COMPLETE URINE EXAMINATION:
LIVER FUNCTION TEST:
SERUM ELECTROLYTES:
SERUM CREATININE:
TREATMENT:
On 3/12/2022:
Tab.Nicardipine 20 mg PO twice daily
Monitor vitals every 2hrly
On 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-2hrly
On 5/12/2022:
-Fluid restriction
-Salt restriction
-Tab.Shelcal 500 once daily
-Tab.Arkamin 0.1mg PO once daily
-Tab.Lasix 40mg PO once daily
-Tab.Nodosis 500mg PO once daily
-Tab.Clinidipine 10mg PO once daily
-Monitor vitals-2hrly
Comments
Post a Comment