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:








Provisional diagnosis:
Young onset hypertension

Treatment:

1)tab.AMLONG 5mg PO/OD

2)tab.ZINCOVIT PO/OD




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