34 year old male with hypertension

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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. 

CASE HISTORY:

A 34 year old male ,mason by occupation came with the chief complaints of:

1.Blurring of vision Right eye more than left eye since 3 years and episodes of giddiness 

2.slurring of speech since 1 year

3.bodypains since 1 year 

HISTORY OF PRESENT ILLNESSES:

Patient was apparently asymptomatic ago,then he developed giddiness and fell during his work

This episode of blackout was not associated with nausea, vomiting, vertigo,tinnitus, earfullness.Then he was taken to a local hospital and was diagnosed with high blood pressure. Since then he had been using medication for hypertension 

 

He developed slurring of speech 1 year ago which was progressive 

Body pains since 1 year 

The recent episode of  blackout was 1 week ago for which he was taken to local hospital and medication was given

His daily routine was disturbed because of blurring of vision and giddiness. He could not work properly.

PAST HISTORY:

He had repeated episodes of blackouts since he was diagnosed with hypertension 

He is a known case of hypertension since 3 years 

No history of diabetes, asthma, tuberculosis, epilepsy

TREATMENT HISTORY:

He has been taking treatment for hypertension for the past 3 years 

He used spectacles for 3 months for blurring of vision

No history of past surgeries 

PERSONAL HISTORY:

Appetite is normal 

Mixed diet

He is taking salt restricted diet 

Sleep is adequate 

Bowel and bladder - normal 

No allergies 

He was an alcoholic and smoker for 10 years 

He used to take 90ml alcohol per day ,1pack of cigars per day

FAMILY HISTORY:

his parents have hypertension 

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative and well oriented to time and place

VITALS on admission:

BP: 270/140 mm hg

 

 given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg 

PR : 90bpm

RR: 18 cpm

Afebrile

All the peripheral pulses  present 

Ankle brachial index > 1.25 

Renal bruit present

BP:

         RT          LT

UL  160/100   170/100

LL  200         200

SYSTEMIC EXAMINATION:

 CVS‐ S1 S2 heard, no murmurs

RS‐ Normal vesicular breath sounds hears

P/A - 

shape of abdomen- scaphoid

No tenderness, no palpable mass

Bruit is heard on right side of umbilicus

CNS EXAMINATION:

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

Higher mental functions are intact

Slurred speech 

Signs of meningeal irritation are absent

CRANIAL NERVES EXAMINATION:

I ‐ sense of smell intact

II- there is blurring of vision Right eye> left eye ,colour vision present

    Visual acuity - right eye - PL,PR present, hand movements perceived, cannot count fingers 

III,IV,VI- able to move eyes in all directions 

         Pupil size - 4mm B/L

        direct light reflex- present 

V- sensation over face is present 

    Motor- weakness of masseter, temporaralis,pterygoids

     Reflexes- 

      Corneal reflex ‐ present 

      Conjunctival reflex- present 

      Jaw jerk -present

VII-Nasolabial fold on right side is not prominent

Angle of mouth deviated to left side slightly 

There is preservation of eye closure 

VIII-  normal hearing, no tinnitus, vertigo 

IX,X- gag reflex present 

Uvula deviated to right side

XI- normal 

XII-no deviation of tongue 

2)MOTOR SYSTEM : 

                      Right          Left

Bulk: 

Inspection.      N.              N

Palpation.        N.             N

Tone: 

UL.                  N.               N

LL.                    N.             N

Upper Limb:

Shoulder: Flexion 5/5.    5/5

Extension.             5/5.     5/5 

Abduction:            5/5.      5/5 

Adduction:            5/5.     5/5 

Elbow: 

Flexion (biceps)    5/5.    5/5 

Extension (triceps)  5/5. 5/5

Lower Limb:

Ilio psoas.                5/5.   5/5

Gluteus max.           5/5   5/5

Adductor femoris.   5/5  5/5

Hamstrings.             5/5   5/5

Quadriceps.             5/5   5/5

Tibialis ant.             5/5     5/5

Tibialis post.           5/5.    5/5

Ex. Digitorum L.     5/5.    5/5 

Fl. Digitorum L.      4/5.    4/5

Ex. Hallucis L.        4/5.    4/5

Deep tendon reflexes:

Biceps:                     +2        +2

Triceps:                   +1      +1

Supinator:               +2        +2

Knee:                       +3          +3

Ankle:                      +3         +3

Plantar:                  extensor        flexor

 Right knee jerk 

Left knee jerk

Ankle jerk 

Sensory:

STT: Crude touch. +          +

Pain.                        +         +

Temp.                      +         +

Post. Dorsal

Fine touch.            present

Vibration.                +       +

Position.                 +      +

CEREBELLUM:

Nystagmus is present in horizontal direction with fast component to left side 

Finger nose test couldn't be performed because of blurring of vision 

knee heel test - normal

Swaying to sides while walking

Unable to walk in in a straight line on his own

Couldn't perform tandem gait

Dysdiadochokinesia

Knee heel test 

INVESTIGATIONS:

On 28/10/21

on fundoscopy there is grade IV hypertensive retinopathy 

DIAGNOSIS:

 Hypertension secondary to renal artery stenosis