A KNOWN CASE OF HYPERTENSION SUFFERING FROM BLURRING OF VISION UNDER EVALUATION

P. Jeshmitha Rollno:104

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-centered online learning portfolio and your valuable inputs on the comment box

A KNOWN CASE OF HYPERTENSION SUFFERING FROM BLURRING OF VISION UNDER EVALUATION 

8th Oct 2021

In AMC right side fourth bed 

35 yr old male patient who is a real-estate agent was previously a construction worker. He is married and he has 3 children he is financially stable person & is a resident of Narketpally. 

Presented to  OPD on 1/10/21

With CHEIF COMPLAINTS OF 

Giddiness & blurring of vision since 6 days 

Weakness in Lower limbs -2days

Burning micturation - 1day 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 6 years back the complaints of intermittent headache and blurring of vision.

1st time:

He complained of headche 6 years back for which he went to government hospital in narketpally and was diagnosed as hypertension.

Then later he developes intermittent headache with blurring of vision which subsided on taking antihypertensive medication. The frequency of episodes were every 3-4 days/week 

 On friday i.e on 1st october he came to opd with same complaints and given treatment( sublingual) On sunday i e 3rd october he came with complaints of acute retention of urine and relieved after foley' s catheterisation.

Patient complaints of giddiness since 3 days and blurring of vision since yesterday morning.

Patient was apparently asymptommatic 3 days back then he developed giddiness which was sudden in onset, non rotational. He was normal after the 1st episode then again developed giddiness since yesterday morning.
He also complaints of headache associated with blurring of vision Vomitings which was non bilious and contains food particles.
H/o generalised weakness since 3  days.

HISTORY OF PAST ILLNESS 

On 25th April 2021 he was tested positive for covid he was suffering from severe shortness of breath and was admitted in KIMS, later he didn't take any medications prescribed to him .He took an ayurvedic juice after 4 months he describe that he was tested covid negative .

*No c/o - chest pain, palpitations, sycopal attacks 

*No c/o - shortness of breath, orthopnea & Paroxysmal nocturnal dyspnea

*No c/o - diabetes, tuberculosis, bronchial asthma and epilepsy. 

H/o - He is k/c/o Hypertension since 6 years and is on T.CLINIDIPINE 10MG AND T.TELMA 40MG

Treatment History :

Diabetes  - Not present

Hypertension  -present 

CAD - Not present 

Asthma - Not present

Tuberculosis - Not present 

Antibiotics - None used

Hormones - None used

Chemo/Radiation - Not given 

Blood Transfusion- Not given 

Surgeries - None

Other - None

Personal History :

Marital Status- married 

Occupation - employed(realestate agent)

Appetite - Normal

Non vegetarian 

Bowels - Regular

Micturition - burning sensation 

Known allergies - None

Habits/addictions : 

*alcohol 

Family History :

Diabetes- No

Hypertension -present (his mother and father are hypertensive patients) 0

Heart diseases - No

Stroke - No

Cancers - No

Tuberculosis  - No

GENRAL EXAMINATION 

O/E - pt is conscious,coherent

Pallor - No

Icterus - No

Cyanosis - No

Clubbing of fingers/toes - No

Lymphadenopathy - No

Oedema of feet - No

Malnutrition - No

O/E - pt is conscious,coherent

Vitals:
Temp: 103.4 F
PR: 117bpm
BP: 150/90mm hg
RR:30cpm
Spo2:97% at room air
CNS:

Higher mental functions: Intact

1. Higher Mental Functions:-

▪️Appearance & behaviour - moderately  built , oriented (at admission)

▪️ Level of consciousness - Conscious

▪️ Cognitive functions :

  

      * Memory & attention - normal 

      * Speech & language - normal  

      

CRANIAL NERVES-

Optic nerve-

Sensory system- sensitive to pain and touch.
Motor system

      Right                 Left
Power-  UL      5/5                    5/5
              LL      5/5                     5/5

Tone-    UL    Normal             Normal
              LL    Normal            Normal

Reflexes-
Biceps            +++                      +++
Triceps           +++                     +++
Supinator       +                          +
Knee             +++                       +++
Ankle             +++                    +++
Plantar       Flexion               Flexion
response   withdrawal response

Gait- Ataxic

Cerebellar system - intact

CVS:S1S2+
RS: BAE+,NVBS
P/A: SOFT, NONTENDER.

Provisional diagnosis:
GIDDINESS UNDER EVALUATION SECONDARY TO ? HYPERTENSION? WITH U/L OPTIC DISC EDEMA WITH PYEREXIA UNDER EVALUATION WITH K/C/O HYPERTENSION.


Treatment:

INJ. MANNITOL 100ml IV/ TID
INJ. ZOFER 4MG IV/ BD
INJ. OPTINEURON 1AMP IN 100ML NS IV/ OD
INJ. CIGXANE 60MG SC/OD
INJ. NEOMOL 100ML IV/ SOS
TAB. VERTIN 16 MG PO/ BD

TAB. PCM 650 MG PO/ TID
Strict temperature monitoring 4th hourly
Strict BP monitoring 2nd hourly

SOAP NOTES

DAY -1 

38 yr / M
S :fever,headache decreased
Blurring of vision present 

O :
Pt  is c/c/c
Temperature : 98.6 F
BP : 130/100mm Hg
PR : 113bpm , regular
CVS : S1 S2 +, no murmur
RS : NVBS + 
P/A : soft, non tender 

A :
GIDDINESS UNDER EVALUATION SECONDARY TO BENIGN INTRACRANIAL HYPERTENSION? WITH U/L OPTIC DISC OEDEMA WITH K/C/O HYPERTENSION WITH  AKI WITH PYREXIA UNDER EVALUATION


Plan of care:- 

INJ. MANNITOL 100ml IV/ QID
INJ. ZOFER 4MG IV/ BD
INJ. OPTINEURON 1AMP IN 100ML NS IV/ OD
INJ. NEOMOL 1g 100ML IV/ SOS
TAB. VERTIN 16 MG PO/ BD
TAB. PCM 650 MG PO/ BD
TAB.METXL 50MG PO/OD
TAB.CINOD 10MG PO/OD
Strict temperature monitoring 4th hourly
Strict BP monitoring 2nd hourly

DAY -2 

38 yr / M
S :headache decreased
Blurring of vision present
No fever spikes 

O :
Pt  is c/c/c
Temperature : 98.6 F
BP : 140/100mm Hg
PR : 113bpm , regular
CVS : S1 S2 +, no murmur
RS : NVBS + 
P/A : soft, non tender 

A :
LEFT OPTIC DISC EDEMA SECONDARY TO OPTIC NEURITIS? WITH ACUTE RETENTION OF URINE SECONDARY TO UMN BLADDER? WITH SECONDARY TO NEUROMYELITIS OPTICA WITH K/C/O HYPERTENSION WITH AKI


Plan of treatment - 

INJ. MANNITOL 100ml IV/ QID
INJ. ZOFER 4MG IV/SOS 
INJ. OPTINEURON 1AMP IN 100ML NS IV/ OD
INJ. METHYL PREDNISOLONE 1G IN 100ML NS IV OVER 30 MIN
INJ. PAN 40MG IV OD
INJ. NEOMOL 1G 100ML IV/ SOS 

TAB. PCM 650 MG PO/SOS
TAB.METXL 50MG PO/OD
TAB.CINOD 10MG PO/OD
TAB. NICARDIA 20MG PO/ SOS
Strict temperature monitoring 4th hourly
Strict BP monitoring 4th hourly