70 year old presenting with denovo 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-centred online learning portfolio and your valuable comments on comment box is welcome. 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. 

A 70 year old male came with chief complaints of blurring of vision and watering of eyes.

Patient was apparently asymptomatic 1 month back then he developed watering of left eye and blurring of vision.
 No H/O palpitations 
No h/o chestpain, shortness of breath
No h/o headache,sweating,burning micturation
No h/o weight loss

Past history

40 years back he had an accident where his leg got fractured. He got admitted in the hospital and had a cast but he took some ayurvedic medine to heal the fracture.



3 years back he got admitted in the hospital for jaundice with fever

Family history :
 
No significant family history 

Personal history :

Diet: mixed
Sleep:disturbed sleep due nocturia ( nearly 5 times)since 1 year
Bowel : normal
Bladder: frequent urination in the night
Addictions: no addictions
No allergies

General examination :

Patient is conscious,coherent,cooperative ,well oriented to time, place and person

Pallor: absent
Icterus: absent
Clubbing:absent
Cyanosis:absent
Lymphadenopathy:absent
Pedal edema: present ( pitting type)















Vitals:

BP:130/90mm hg
PR:70bpm
Temp: afebrile
RR: 16
He has pedal edema of pitting type.

Systemic examination :

CVS - S1 S2 heard
R/S - inspection
shape - scaphoid 
No wheeze 
No scars present
Palpation:
no palpable mass,
Trachea- central
Auscultation:
Vesicular breath sounds heard
No dyspnea
P/A - 
Inspection - obese abdomen, Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.
PALPATION:   Soft, non tender, no organo megaly.
AUSCULTATION:
BOWEL SOUNDS HEARD
CNS - NO focal deficit found.
On eye examination: bilateral immature cataract is present.

Diagnosis:

Denovo hypertension 

Investigation :

Serum creatine:1.1

Sodium:136 Normal(136-145)

Potassium:4.4. Normal(3.5-5.1)

Chloride :102. Normal(98-107)

Total bilirubin:2.3. Normal(0-1)

Direct bilirubin:0.01. Normal(0.0-0.2)

AST:19. Normal(0-35)

ALT:14. Normal(0-45)

ALP:78. Normal(56-119)

Total protein:8.2. Normal(6.4-8.3)



Treatment : patient was given nicardia 10 mg 




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