YOUNG-ONSET HYPERTENSION
A 34 YEAR OLD MALE WITH YOUNG-ONSET HYPERTENSION
May 29th 2021
SOWJANYA REDDY PALAKURTHY
Roll no. :130
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 a diagnosis and treatment plan.
CASE:
A 34 Year Old Male, presented to the OPD on 22/04/2021 with Chief Complaint of Headache since 2 months.
HOPI:
The patient was apparently asymptomatic 2 months ago and then developed headache which was not continuous (on and off). It was insidious in onset and progressive in nature, Headache was of throbbing type. He also complained of increase in frequency of attacks.
*The headache gets aggravated on increased work load and stress and decreased on taking rest /sleeping.
*On regular health checkup in their workplace he was diagnosed with Hypertension 1 year ago but did not take any medication for it as such.
*No H/O of Fever, Nausea, Blurring of vision, watering of eyes, SOB, Pedal Edema, chest discomfort, Facial puffiness or any weakness in body parts.
* He came to the OPD again on 3/05/2021 for follow-up
PAST HISTORY: No similar complaints in the past
*Patient is a K/C/O HTN since 1 year and is not on any medication.
* N/K/C/O: DM, TB, BA, Epilepsy
PERSONAL HISTORY:
Diet - Mixed ( Salt intake- Normal)
Appetite- Normal
Sleep- Adequate , but sometimes disturbed due to stress and increased headache
Bowel and Bladder movements- Regular
No addictions
No allergies
FAMILY HISTORY: The patient's father had HTN and died due to renal failure.
* No H/O DM
GENERAL EXAMINATION: The Patient was examined in a well lit room after taking informed consent.
He was Conscious, coherent, cooperative at the time of examination, Well oriented to time, place and person.
The patient is well built and nourished
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Lymphadenopathy: Absent
Edema: Absent
VITALS:
1. Pulse Rate: 72bpm
Right upper limb peripheral pulse feable
Bi lateral brachial pulses felt
Bilateral posterior tibial pulses not felt
2. Blood Pressure:
Rt UL - 180/100mmHg
Lt UL - 150/110mmHg
Rt LL - 190/110mmHg
Lt LL - 170/100mmHg
3. Temperature: Afebrile
4. Respiratory Rate: 14 cycles/min
SYSTEMIC EXAMINATION:
CVS: No visible pulsations, no increased JVP, Apex beat Lt. 5th ICS mid clavicular line,
S1 S2 Heard, no murmurs.
Radio Radial delay and radio femoral delay +
RS: BAE+
ABDOMEN: Soft, non-tender, no organomegaly
INVESTIGATIONS:
On 22/04/2021
COMPLETE BLOOD PICTURE(CBP)
Interpretation: Normal blood picture
COMPLETE URINE EXAMINATION
Interpretation: Within the normal range
On 3/05/2021
ERYTHROCYTE SEDIMENTATION RATE
Interpretation: ESR is within the normal range
C-REACTIVE PROTEIN (CRP)
Interpretation: Normal
THYROID PROFILE- T3, T4, TSH
Interpretation: Normal study
LIPID PROFILE
Interpretation: Normal
BLOOD SUGAR FASTING
Interpretation: Normal
RENAL FUNCTION TESTS
Interpretation: Normal
CT PERIPHERAL ANGIOGRAM B/L UPPERLIMBS
Interpretation: Normal Bilateral Upper limb angiogram
CT AORTOGRAM (CHEST & ABDOMEN)
Interpretation: Normal study
COLOUR DOPPLER 2D ECHO
Interpretation:
No MR/AR/TR
No RMWA, No AS/MS
Good LV Systolic functions
No diastolic dysfunction, no PAH
ULTRASOUND REPORT
Interpretation: The patient has Right renal calculus (5-6mm) and Grade I Fatty Liver
PROVISIONAL DIAGNOSIS: 34 Year Old Male with Young Onset Hypertension
TREATMENT:
Tab. CILNIDIPINE 10mg OD
Tab. CHLORTHALIDONE 12.5mg
Tab. TELMISARTAN 40mg OD
(DILNIP TRIO)
