70 Y/F With DENOVO Hypertension

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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   

8- NOVEMBER -2023

70 year old female came to opd with complaints of

Swelling of limbs ( left>> right) since 3 years

Generalized body malaise since 3 months

HISTORY OF PRESENTING ILLNESS

Pateint was apparently asymptomatic 3 years ago , then she developed swelling of limbs, Left>>>Right, insidious in onset and gradually till knee, non pitting type, associated with itching.

No h/o pain, skin changes and discharge

Patient also complains of generalized body malaise since 1 month

No relieving and aggrevating factors

No h/o fever, cold, cough, sob

No h/o any other complaints

PAST HISTORY

K/c/o filariasis since 3 years

Not a k/c/o DM,HTN, TB,Asthma,Epilepsy 

PERSONAL HISTORY:

She is Married

She consumes mixed diet 

Sleep is adequate 

Appetite normal

Bowel and bladder movements are regular

MENSTRUAL HISTORY: 

Age at menarche:12 years

Cycle: 30/5 days, Normal flow

Menopause @ 35 years ago.

OBSTETRIC HISTORY:

Age at Marriage:19 years

1st pregnancy: conceived after 1 month of pregnancy,NVD, 

2nd pregnancy: conceived after 6 months of 1st pregnancy NVD.

FAMILY HISTORY:

No similar complaints in family 

GENERAL EXAMINATION:

Patient is conscious, coherent and co-operative,well oriented to time,place and person.

Moderately build and malnourished.

Examination was done in a well lit room.

No Pallor,Pedal edema, Icterus, cyanosis,clubbing,lymphadenopathy

VITALS 

PR- 96 bpm

BP- 180/80 mm Hg

RR- 16 cpm

Temp -100 F

GRBS - 144 mg/dl

SYSTEMIC EXAMINATION

ABDOMEN 

Inspection

Shape - Slightly distention.

Umbilicus - Everted

Equal movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars , sinuses 

Palpation

Soft, non tender

Auscultation

Bowel sounds heard

RESPIRATORY SYSTEM 

Bilateral air entry present

CVS EXAMINATION 

S1 S2 heard, no murmurs

CNS EXAMINATION 

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal sensations

Motor examination normal

Reflexes normal

INVESTIGATIONS

PROVISIONAL DIAGNOSIS

DENOVO HYPERTENSION

K/c/o Filariasis

TREATMENT

Tab. Amlong 5 mg PO OD

Tab. MVT PO OD

Tab.Diethylcarbamazine citrate (DEC) X 4 weeks

BP monitering 2 hrly