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PATIENTS DATA

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

Clonidine hydrochloride sublingual


No maintenance medication
Ranitidine once a day
Medication unrecalled
4 days hospitalization
No complications

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

PERSONAL AND SOCIAL HISTORY:


Patient EPD is a medium built religious 42 year old habal-habal driver. He is
very active in church and its organizations. He is married with two children. He
wakes up at 4:00 AM and sleeps at around 10:00 PM. He eats three times a day with
no snacks. His diet consists of rice (1-2 cups per meal), vegetables, and dried fish.
He does not exercise much. He quit smoking at 32 years old (0.6 pack year smoker,
from1994 to 2006). He is an alcoholic beverage drinker. He wears a helmet when
driving and follows the traffic rules and speed limit. He can do activities of daily
living. He drinks more than 8 glasses of water daily, defecates twice a day, and
urinates around 2L per day. He admits to being happy but often worries about
financial problems. He has a loving family and a lot of friends. He loves to cook.

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:

(-) Color changes

(-) Weight gain or loss

Skin:

(-) Hair and nail changes

(-) Fatigue

(-) Rashes

Head:

(-) Fever

(-) Lumps

(-) Headache

(-) Weakness

(-) Pruritus

(-) Head injury

(-) Trouble sleeping

(-) Dryness

(+) Nape pain

Ears:

(-) Hoarseness

(-) Change in appetite

(-) Decreased hearing

(-) Thrush

(-) Nausea

(-) Tinnitus

Neck:

(-) Change in bowel habits

(-) Ear pain

(-) Lumps

(-) Rectal bleeding

(-) Drainage

(-) Swollen glands

(-) Constipation

Eyes:

(-) Pain

(-) Diarrhea

(-) Vision loss/change

(-) Stiffness

(-) Jaundice

(+) Glasses/ contact


lenses

Breast:

Urinary:

(-) Lumps

(-) Frequency

(-) Pain

(-) Urgency

(-) Pain
(-) Redness

(-) Discharge

(-) Dysuria

(+) Blurry or double


vision

Respiratory:

(-) Hematuria

(-) Flashing lights

(-) Cough

(-) Incontinence

(-) Glaucoma

(-) Hemoptysis

(-) Change in Urinary


strength

(-) Cataracts

(-) Shortness of breath

Nose:

(-) Wheezing

(-) Nasal congestion

(-) Dyspnea

(-) Discharge

Cardiovascular:

(-) Itching

(-) Chest pain

(-) Epistaxis

(-) Tightness

Mouth and Throat:

(-) Palpitations

(-) Bleeding

(-) SOB with activity

(-) Dentures

(-) Orthopnea

(-) Sore tongue

Gastrointestinal:

(-) Ulcerations

(-) Dysphagia

(-) Dry mouth

(-) Odynophagia

(-) Sore throat

(-) 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:

(-) Heat/cold intolerance

(-) Weakness

(-) Easy bruising

(-) Excessive sweating

(-) Numbness

(-) Easy bleeding

(-) Polyuria

(-) Tingling sensation

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.

Cranial nerve assessment

Olfactory

Able to smell on both nares

Optic

Can see using each eye. Visual acuity not


assessed. Pupillary light reflex intact. Normal
visual fields on visual confrontation test.

Oculomotor,
Abducens

Trochlear,

Trigeminal

Intact sensation on face. Can clench jaws.


Can exhibits facial muscle movements
bilaterally.
Able to respond to normal voice tones
Able to keep head at midline and has good
balance while standing

Facial

Vestibulocochlear

Glossopharyngeal,
Hypoglossal

Spinal Accessory

Motor Strength

Reflexes

Pupils are equally round and reactive to


light. Able to move eyes to the H
directions. No nystagmus. No ptosis

Vagus,

Able to move tongue with no deviations


noted upon protrusion. Uvula midline. Able
to swallow. Gag reflex intact.
Shoulder symmetrical and can move against
resistance.
Can move head from side to side against
resistance.

Salient Features:

Male

42 years old

with a history of hypertension


dizziness
blurring of vision
nape pain, 6/10 on the pain scale
No diaphoresis, palpitations, body malaise, loss of consciousness, abdominal
pain, headache, nausea and vomiting reported.
Family history of Hypertension
Diet consists of dried fish
Physical Examination: BP 150/90 mmHg right arm sitting

Impression:

Hypertension I

DDX:

Migraine

Stroke

RULE IN
(+) blurring of vision
(+) dizziness
(+) Nape pain

(+) blurring of vision


(+) dizziness

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

with unknown cause

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

eating an unhealthy diet


consuming excess salt
drinking alcohol
smoking
sleep apnea
stress

Diagnosis
There are a few types of high blood pressure depending on severity.

prehypertension: 120/80 mmHg or higher


stage 1 high blood pressure: 140/90 mmHg or higher
stage 2 high blood pressure: 160/100 mmHg or higher
hypertensive crisis (a life-threatening condition): 180/110 mmHg or higher

Tests and Treatments


The test to determine if you have high blood pressure is simple and noninvasive. Measuring the blood pressure with a sphygmomanometer several times
over a few days is done to get an accurate reading. Treatments include:
reducing the amount of salt in your diet
exercising and losing weight
beginning a smoking cessation plan
trying to reduce stress with some relaxation techniques
diuretics
beta blockers
calcium channel blockers
ACE inhibitors
vasodilators
Complications
High blood pressure can stretch out arteries and weaken them (an
aneurysm). It can lead to an abnormal heart rhythm (arrhythmia). It can also make
the patient more likely to have a heart attack or heart failure, kidney problems, or
stroke.
Prevention
Eat a healthy low-sodium diet
Exercise regularly
Try to maintain a healthy weight
Quit smoking
Be sure to take medication for high blood pressure as directed
Monitor blood pressure.

REFERENCES:

About high blood pressure. (2014). Retrieved from


http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBlo
odPressure/About-High-Blood-Pressure_UCM_002050_Article.jsp
High
blood
pressure
facts.
(2014).
Retrieved
from
http://www.cdc.gov/bloodpressure/facts.htm
Mayo Clinic Staff. (2014). High blood pressure. Retrieved from
http://www.mayoclinic.org/diseases-conditions/high-bloodpressure/basics/definition/con-20019580
Understand your risk for high blood pressure. (2014). Retrieved from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYo
urRiskforHighBloodPressure/Understand-Your-Risk-for-High-BloodPressure_UCM_002052_Article.jsp

Hypertension
Patient EPD Case Presentation

Presented to
The Department of Community Medicine
Davao Medical School Foundation Inc.
SY 2016-2017

In Partial Fulfillment of the Requirements in


Community Medicine

Submitted by:
Ty, Gelyn M.
MEDICINE 4
JULY 2016