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Name:
EPD
Age/Sex: 42/M
Marital Status: Married
Religion: Protestant
Address: Purok Niyog, Barangay Wines, Baguio District, Davao City
Date/Time of Consultation: July 17, 2016
Date/Time of Interview: July 20, 2016
Source and Reliability: Patient; 90%
CHIEF COMPLAINT: Sudden dizziness and blurring of vision
HISTORY OF PRESENT ILLNESS
Patient EPD is a 42 year old male with a history of hypertension and gastric
ulcer.
1 day prior to consultation, patient experienced sudden dizziness and blurring
of vision during his drive to the city proper. This was accompanied by nape pain,
6/10 on the pain scale. No diaphoresis, palpitations, body malaise, loss of
consciousness, abdominal pain, headache, nausea and vomiting reported.
Persistence of the above symptoms prompted the consultation.
PAST MEDICAL HISTORY
Childhood Illnesses: Measles, Mumps, Varicella Infection (2015), Benign
Febrile Seizure
Medical:
1998 Hypertension
(taken twice only)
1999 Gastric Ulcer
Hospitalizations:
2006 Cerebral Malaria
Surgeries: None
Psychiatric: None
Health Maintenance:
Childhood immunization with visible BCG scar on right deltoid.
Last check-up 2006
Maintenance medications taken:
Ranitidine for gastric ulcer only
FAMILY HISTORY
Maternal: Hypertension
Paternal: Hypertension, Lung Cancer
Environmental History:
Patient lives in a bungalow wooden house with his wife and 2 children. They
have a pet cat. They have a wide open backyard with ornaments and flower pots.
Travel History:
No recent travel to other places.
REVIEW OF SYSTEMS
General:
Skin:
(-) Fatigue
(-) Rashes
Head:
(-) Fever
(-) Lumps
(-) Headache
(-) Weakness
(-) Pruritus
(-) Dryness
Ears:
(-) Hoarseness
(-) Thrush
(-) Nausea
(-) Tinnitus
Neck:
(-) Lumps
(-) Drainage
(-) Constipation
Eyes:
(-) Pain
(-) Diarrhea
(-) Stiffness
(-) Jaundice
Breast:
Urinary:
(-) Lumps
(-) Frequency
(-) Pain
(-) Urgency
(-) Pain
(-) Redness
(-) Discharge
(-) Dysuria
Respiratory:
(-) Hematuria
(-) Cough
(-) Incontinence
(-) Glaucoma
(-) Hemoptysis
(-) Cataracts
Nose:
(-) Wheezing
(-) Dyspnea
(-) Discharge
Cardiovascular:
(-) Itching
(-) Epistaxis
(-) Tightness
(-) Palpitations
(-) Bleeding
(-) Dentures
(-) Orthopnea
Gastrointestinal:
(-) Ulcerations
(-) Dysphagia
(-) Odynophagia
(-) Heartburn
Peripheral Vascular:
(-) Calf pain when walking
(-) Leg cramps
Musculoskeletal:
(-) Muscle or joint pains
(-) Stiffness
(-) Back pain
(-) Redness on joints
(-) Joint swelling
(-) Trauma
Neurologic:
(+) Dizziness
(-) Fainting
(-) Seizures
Hematologic:
(-) Weakness
(-) Numbness
(-) Polyuria
Endocrine:
(-) Polydipsia
(-) Tremors
(-) Polyphagia
PHYSICAL EXAMINATION
General Survey: Patient EPD is seen sitting on a chair, awake, conscious, coherent,
and cooperative, not in respiratory distress, with appropriate affect, and appears
well-groomed. Vital Signs:
Vital Signs BP = 150/90 mmHg right arm sitting, 150/100 mmHg after 30 minutes
CR = 77bpm
RR= 23cpm
T= 36.8C
Measurements
Weight: 73kgs
Height: 1.7272 m (58 ft)
BMI: 24.49 kg/m2; Normal BMI
Skin and Nails: Skin is dry, rough, with uneven tone. No rashes, bruises, jaundice,
open wounds, sores or any lesions seen. Three rounded depressed scars, measuring
approximately 1x1cm each, noted on right anterior leg, four on the left anterior leg.
Hair is short, black, evenly distributed. No infestations and scaling noted. Nails are
well groomed except for the fifth digit. No clubbing noted. Skin is warm and moist.
Good skin turgor at less than 1 second. Capillary refill noted at 2 seconds.
Head: Head is normocephalic with smooth contours. No palpable mass, sores or
other lesions.
Eyes: Eyebrows and eyelashes black and evenly distributed. No lesions around the
eyes. No swelling and discharge noted on lacrimal glands. Non-icteric sclerae.
Conjunctivae pink. Corneas clear. Both irises are dark brown and symmetric in size.
Red reflex present. Pupils round, symmetrical, reactive to light and accomodation.
Extra-ocular muscle functions normally. Fundoscopy not done.
Ears: Both ears are levelled, symmetrical in shape, in line with outer canthi of eyes.
No tenderness, lesions, discharge, or masses noted. Otoscopic examination not
done.
Nose: Nasal septum midline. Both nostrils patent Nasal discharges not noted upon
inspection. Mucosa pink. No swelling, tenderness, redness or lesions noted on nasal
mucosa. Frontal and maxillary sinuses non-tender upon palpation.
Mouth and Throat: Lips brown and dry, with linear cracks on lower lip. Buccal
mucosa and hard palate pink. Uvula at midline. Tonsils symmetrical, not swollen,
pink. Frenulum located at the midline connected to the floor of the mouth. Tongue
freely moves with no deviation. No dentures used. With a complete set of teeth. No
other masses and lesions noted.
Neck: Neck with trachea positioned at midline. No distended neck veins nor carotid
bruits. With nape pain. No palpable masses, lymphadenopathy, and tenderness
noted. Thyroid not enlarged. With good ROM of the neck.
Thorax and Lungs: Chest wall expansion symmetrical without retractions.
Breathing regular. Tactile fremitus symmetrical. Lungs are resonant. No adventitious
lung sounds heard on both lung fields.
Breast and Axillae: Not assessed
Cardiovascular: The point of maximal impulse not located. No visible pulsations
noted. Heart rate is regular. No palpitation, murmurs or thrills noted.
Abdomen: Abdomen flat and symmetrical. Umbilicus midline. No surgical scars
noted. No varices, lesions, and hematoma seen. Bowel sounds are normal at 17 per
minute best heard at right hypochondriac area. Soft to touch with nonpalpable liver
edge. No other masses palpated. No tenderness noted.
Back: Spine at midline. No deformities seen.
Genitalia: Not assessed
Extremities/Musculoskeletal: Muscles on both sides of the body are symmetrical
in shape and size, toned, with equal strength. No joint deformities. No lesions,
bruises, open wounds noted. Range of motion and coordination are normal. No
contractures or tremors noted.
Peripheral Vascular: No bipedal edema. No signs of venous stasis and arterial
insufficiency in the legs. No pigmentation of the ankles. No spider veins on thighs
and legs bilaterally. No clubbing of fingernails. CRT <2secs on both upper and lower
extremities. Upper and lower extremities warm to touch. Peripheral pulses are
equally strong bilaterally.
Neurologic
Mental Status
- Cooperative. Thought coherent. Oriented to place, person, and time.
Olfactory
Optic
Oculomotor,
Abducens
Trochlear,
Trigeminal
Facial
Vestibulocochlear
Glossopharyngeal,
Hypoglossal
Spinal Accessory
Motor Strength
Reflexes
Vagus,
Salient Features:
Male
42 years old
Impression:
Hypertension I
DDX:
Migraine
Stroke
RULE IN
(+) blurring of vision
(+) dizziness
(+) Nape pain
RULE OUT
(-) headache on one side
or both sides of the head
(-) throbbing or pulsing
pain
(-) sensitivity to light or
sounds
(-) nausea and vomiting
(-) paralysis
(-) numbness or weakness
(-) confusion
(-) slurring speech
(-)
severe,
sudden
headache
with
an
Hypoglycemia
(+) dizziness
(+) blurring of vision
Anxiety Disorder
(+) dizziness
(+) blurring of vision
Menieres Disease
- disorder of the inner ear
(+) dizziness
unknown cause
(-) rapid heartbeat
(-) sudden mood changes
(-) unexplained fatigue
(-) pale skin
(-) headache
(-) hunger
(-) loss of consciousness
(-) fatigue
(-) restlessness
(-) irritability
(-) short of breath
(-) tachycardia
(-) hearing loss
(-) tinnitus
(-) aural fullness
DISCUSSION:
High blood pressure (hypertension)
It is a serious condition that affects one in three adults in the United States,
according to the Centers for Disease Control and Prevention (CDC). Its called the
silent killer because people often have no symptoms, yet it can lead to some
serious and sometimes even fatal conditions.
According to the American Heart Association, a blood pressure reading of less
than 120/80 mmHg is considered normal. You are diagnosed with high blood
pressure (hypertension) if your blood pressure readings are consistently above
140/90 mmHg.
Causes
For most cases of high blood pressure there is no known cause. This is called
primary hypertension. For others, certain medical conditions like kidney or heart
conditions can cause high blood pressure. This is called secondary hypertension.
Risk Factors
Age: Older adults are at greater risk for high blood pressure.
Gender: Women over 65 are more likely to have higher blood pressure, and
men under age 45 are more likely to have high blood pressure than women.
Race: African-Americans are more likely to have high blood pressure.
Family history: If your direct family members (parent or sibling) have high
blood pressure, you are more at risk.
being overweight
not exercising enough
Diagnosis
There are a few types of high blood pressure depending on severity.
REFERENCES:
Hypertension
Patient EPD Case Presentation
Presented to
The Department of Community Medicine
Davao Medical School Foundation Inc.
SY 2016-2017
Submitted by:
Ty, Gelyn M.
MEDICINE 4
JULY 2016