35 YEAR FEMALE WITH HIGH BP

 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.




A 35 year old female r/o athmakuru came to the casualty for follow up i/v/o high bp.

FIRST VISIT
on 13/9/21 pt came with c/o fever a/w chills,cold,cough since 3 days( for which she consulted a local RMP, some injections were given , but the symptoms didn't subside so the patient came to our hospital)
on examination her bp was 180/100 mmhg , advised T.Telma 20mg PO/OD and asked for regular bp monitoring at home (ECG showing LVH, Alb+ 2/1,Hb- 10.7,Tlc- 3600,plt-2.36)
Regular BP checkup was done ( which showed 180/100 170/100 mm hg alternatively).
Her Fever and other symptoms were reduced by medication, but as the patient had consistent high BP she was advised for a follow up after 1 week.

SECOND VISIT
ON 18/9/21 
pt came for follow up i/v/o high bp (210/140 mmhg) 
No E/O target on damage, no h/o blurring of vision , angina, reduced UO

Past History: H/O Gestational HtN 10 yrs back.
patient has 2 children.
1st pregnancy: 8th month> high BP> put on medication> normal delivery was done.
2 nd pregnancy: 8th month> high bp> was put on medications> LICS was done.

No H/O DM,TB, Epilepsy, Thyroid.
No other surgeries were done.

O/E
Pt is c/c/c.
moderately built and nourished
Temp: Afebrile.
BP: 230/140 mmhg.
PR: 88bpm.
RR: 20 Cpm.

CVS :s1s2 heard.
RS: BLAE+, NVBS
P/A : Soft,non tender
CNS: NAD.

DIAGNOSIS
HYPERTENSIVE URGENCY.
PRIMARY ALDOSTERONISM UNDER EVALUATION

TREATMENT GIVEN
initially T.NICARDIA 20 mg PO STAT was given when BP was 210/10 mm hg.

later in the evening when her
BP raised to 240/130 mm hg 
INJ.LABETOLOL 10 mg Iv STAT given.

now her blood pressure has decreased to 160/100 mmhg and is on
TAB. TELMA-AM (40/5) PO/OD.

INVESTIGATIONS





OPHTHALMOLOGY REFERRAL: In view of any fundus changes( Hypertensive Retinopathy) was done, which revealed Normal Fundus.
20/9/21


21/9/21


24/9/21


CLINICAL IMAGES




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