A 25year old female with young onset hypertension
11/6/22
General medicine final practical short case
Name:M.Srilekha
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
Chief complaints:
History of presenting illness:
No H/O chest pain palpitations shortness of breath
No H/O of pedal edema
NoH/O decreased urinary output
No H/O seizures
No H/O headache blurring of vision
Past history:
Diagnosed with hypertension during fist pregnancy first pregnancy: intrauterine death at 6th month
She had hyperemesis during first pregnancy in the first trimester
Second pregnancy: baby delivered at 8 th month normal vaginal delivery and died with in one day
Not a known case of diabetes Mellitus, TB, asthma, thyroid disorders , epilepsy
No past surgical history
No blood transfusions done
Menstrual history:
Age of menarche: 13 years
28 day cycle regular bleeds for 3 days
Associated with back ache
Not associated with clots
Marital history:
Married in 2020 non consanguineous
Personal history:
Occupation : house wife
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder: regular
No addictions
Family history:
Not significant
General examination:
Patient is conscious coherent and cooperative
well oriented to time place and person moderately built and nourished.
Height :161cm
weight:58kg
BMI:22.3kg/m2
No pallor
icterus
cyanosis
clubbing
generalised lymphadenopathy
edema
Vitals pulse rate:90bpm
BP:170/100 mmHg
Respiratory rate:22cpm
Temperature: afebrile
SpO2: 98%
GRBS 164 mg%
Systemic examination:
CVS
Auscultation:S1 S2 sounds heard
no murmurs and
no added sounds
Abdominal examination:
Inspection
Shape scaphoid
Umbilicus inverted
No visible gastric peristalsis
Hernial orifices free
Palpation
soft ,non tender ,no organomegaly
Bowel sounds heard on auscultation
Respiratory system :
Inspection
trachea central in position
Chest movements symmetrical
Auscultation:
BLAE present
NVBS heard
Investigations:
1)tab.AMLONG 5mg PO/OD
2)tab.ZINCOVIT PO/OD
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