Case of hypertension

 

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 


60 year old male Pt came with the complaints of 
abdominal distension since 15 days swelling of both lower limbs, upperlimbs 
facial puffiness since 4 days 
 difficulty in breathing since 2-3 days

HOPI:
Patient was apparently alright 15 days back when he developed abdominal distension which developed gradually a/w b/l pedal edema, pitting type (R>L) , upper limbs edema and facial puffiness . Since 2-3 days he has SOB which is of grade II/ III 
No h/o fever, decreased urine output, heamaturia and frothy urine
No h/o chest pain/palpitations/giddiness/ neck pain 
H/o CVA (right hemiparesis resolved now) 11 years back when he was also diagnosed with hypertension 
H/o hypertension since 11 years on telmibind amh po/od
H/o diabetes since 5 years on glimi m2 po/bd
H/o right lower limb cellulitis 7 years back
H/o ?right lower limb filariasis

Personal history:
Sleep-normal
Appetite-normal
Bowel and bladder movements-normal

Addictions:
Alcohol: occassionally
Tobacco smoking: smoker 4 yrs back stopped now

General examination:

Vitals at presentation
Bp 200/100
PR 90bpm
Grbs 52mg/dl
RR 18cpm
Pt has
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Pedal oedema+ pitting type grade-3 

CVS examination:
S1S2 +NO MURMURS 

Respiratory examination :
BAE +, NVBS 

Per abdomen examination 
abdomen distended,
Soft, non tender, bowel sounds present
Fluid thrill- , shifting dullness -

CNS-
NFND

INVESTIGATIONS:

On 27/11/22


Diagnosis:
HTN urgency
CKD(?DIABETIC NEPHROPATHY,CUE-alb+,creat-3)
DM with OHA induced hypoglycemia 
HEART FAILURE WITH PRESERVED EJECTION FRACTION(chambers dilated with concentric LVH On echo)

Treatment:
Day-1:
1)INJ LASIX 40mg / IV/ TID
2) TAB. CILNIDIPINE 10MG / PO/ BD
3) TAB.MET - XL 25 mG | PO / OD
4)TAB ECOSPIRIN AV PO /OD
4)TEMP, GRBS, PR, BP, RR CHARTING 2nd hrly

Day-3:

AMC BED 4
DAY-3
28/11/22

S:
No stools passed 
No fever spikes

O
Pt is C/C/C
BP:150/100mmHg
PR:90bpm
Temp : 98.6F
GRBS : 121mg/dl
CVS:S1S2 +NO MURMURS 
RS :BAE +, NVBS 
CNS-NFD
P/A:SOFT,NT
I/O - 1400/1500mL

A
HTN urgency
CKD(?DIABETIC NEPHROPATHY,CUE-alb+,creat-3)
DM with OHA induced hypoglycemia 
HEART FAILURE WITH PRESERVED EJECTION FRACTION(chambers dilated with concentric LVH On echo)

P

1)INJ LASIX 40mg / IV/ TID
2)INJ.LABETALOL 10mg/IV/SOS
3) TAB.MET - XL 25 mG | PO / OD
4)TAB ECOSPIRIN AV PO /OD
5)TAB.ARKAMINE 0.1mg PO/TID

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