20 YEAR OLD FEMALE WITH HYPERTENSION

 "This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

November 11,2021

20 YEAR OLD FEMALE WITH YOUNG HYPERTENSION 

__


20 year old female patient resident of  sagar who is a BSE degree student  came to the OPD on 10th November with complaints of high blood pressure

Patient was apparently asymptotic 1 year ago then she developed fever for which she went to the hospital.On examination her blood pressure was 170/90 mm of Hg, no further evaluation or follow up was done as they thought it was due to fever.

5 days ago she went to a dermatologist with complaint of hypo pigmented spots on upper  back.Then on examination her blood pressure was 180/110mm of Hg.Then she was brought to our hospital by her elder sister and mother


    


No h/o headache 

No h/o blurring of vision 

No h/o decreased urine output   

No h/o polyuria,polydypsia,polyplegia

Not a k/c/o HTN, CAD, CVA, Asthma,DM

Personal History :

Diet- mixed 

Sleep- adequate 

Appetite- normal

Bowel and bladder movements- regular 

Addictions- none


Family history : Father and grandfather is a k/c/o HTN


General examination:

No pallor 
No cyanosis 
No icterus 
No lymphadenopathy 
No edema

Vitals

Temperature:98.2f
Pr:102bpm 
Rr:16cpm
Bp:
Upper limb-
Left :180/110mmHg
Right :160/110mmHg  
Lower limb -
 Left - 260/130 mm Hg Right - 190/130 mm Hg
Spo2:98% at RA

Cvs:s1s2+

Respiratory :BAE present 

P/A:soft ,non tender 

CNS:NAD 

Vitals on 10/11/21 
                    RIGHT             LEFT
8 PM     UL-160/100        UL-180/110
              LL-180/130        LL-170/120       

Vitals on 11/11/2021:

                     RIGHT               LEFT

12 AM  UL- 180/120         UL -170/100

              LL-190/140          LL-200/140

4  AM   UL-160/110          UL-160/120

             LL-190/160        LL-190/150

8 AM   UL-160/110        UL-160/120

            LL-20P/150         LL-210/150

4 PM   UL-160/120         UL-140/100

            LL-160/100         LL-170/100

INVESTIGATIONS:








Renal aretery Doppler to be done on 13 November 

       

PROVISIONAL DIAGNOSIS:denovo HTN under evaluation 

TREATMENT :

Tab. Cilinidipine po TID

Tab.Ultracet 1/2 tab QID

BP charting 4 hourly

Inform SOS

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