CASE DISCUSSION ON YOUNG-ONSET HYPERTENSION

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CASE DISCUSSION ON YOUNG ONSET HYPERTENSION

SOWJANYA REDDY PALAKURTHY

Roll no. :130

May 29th 2021

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

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: 

1. Tab. CILNIDIPINE 10mg OD
2. Tab. CHLORTHALIDONE 12.5mg
3. Tab. TELMISARTAN 40mg OD 

 (DILNIP TRIO)