A 42 YEAR OLD PATIENT WITH PALPITATIONS, SOB AND HEADACHE.

 This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


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 histoty, clinical findings, .investigations and come up with a diagnosis and treatment plan. 
A 42 year old male patient came with the  palpitations since  morning , difficulty in breathing since morning, Headache since morning ,Frothy urine 15-20 days ago (not present now)

HISTORY OF PRESENTING ILLNESS-

Pt was apparently alright till morning when he had  palpitations and SOB grade II. He also had complaints of headache which is diffuse.  nausea not a/w lacrimation/photophobia/phenophobia

Since 15 days he has  frothy urine which was  intermittent , resolved now

No  chest pain/ orthopnea/syncopal attacks

No pain abdomen, loose stools, fever, constipation,burning micturition, vomitings

No  tingling/ paresthesis/ involuntary movements 

No  neck pain, giddiness

PAST HISTORY-

 similar complaints in the past apong with chest pain , pain abdomen and malena 1 year back diagnosed with uncontrolled hypertension and AKI on CKD and was given medication which he used for 3 months and then stopped

ADDICTIONS:

Alcohol:since 20 yrs 2/3 times per week (5/6 units)

PERSONAL HISTORY: 

Appetite -normal

Bowel and bladder movements:normal

No allergies

GENERAL EXAMINATION-

Pallor - ab

Icterus- ab

Cyanosis- ab

Clubbing- ab

Pedal edema- ab

VITALS AT PRESENTATION:

Bp- 180/110

Pr- 120 , regular ( ECG sinus tachycardia)

SYSTEMIC EXAMINATION-

CVS: S1S2

RESPIRATORY SYSTEM:BLAE +

ABDOMINAL EXAMINATION:SOFT,NT,bowel sounds+

CNS:NFND

INVESTIGATIONS

PROVISIONAL DIAGNOSIS-

PROVISIONAL DIAGNOSIS-

Hypertension urgency

 hypertension since 1 year, 

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