OPD3- 55 years male with chief Complaint of hypertension and c/o hemorrhoids

Hi, I am Y.Varunkarthik , 5th semester medical student. 

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 patients 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 comment box is welcome. 

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.  

CONSENT AND DE-IDENTIFICATION : 
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Chief Complaint  
55 years male came to OPD for routine medical follow up and also had a complant of hemorrhoids since 4 years.

History of Present illness 
Patient was apparently asymptomatic 4 years ago then he developed hemorrhoids , which had pain intially on defecation later the pain was  reduced on medication.
Also experiences increased range of blood pressure since 1week.
No h/o blood in stools.
No h/o constipation, diarrhoea.
No h/o burning micturition
No h/o low urine output.

History of past illness
Patient has an increased range of blood pressure since 1week.
N/k/c/o DM/cad/epilepsy/ asthma/td

Personal history
Married
Mixed diet
Normal appetite
Regular bowel and bladder movements
Adequate sleep
No allergies 
Addiction - had habit consuming alcohol more than 90 ml /day back 4 years ago ,now reduced the quantity and consuming once on a while.
Had habit of ciggerate smoking occasionally.

General examination
I have taken prior consent of patient.
Patient was examined in well light room.
Patient is conscious , coherrent , co-operative, well oriented to time place and time.
No pallor , icterus , clubbing,
cyanosis , pedal edema ,                    lymphadenopathy.
Vitals 
Temperature-afebrile
Bp-130/90
PR-74 bpm
RR-20 cycles/ min. 
Systemic examination 
 
CVS: 
No thrills
S1,S2 are heard
No murmurs

Respiratory examination:
- Dyspnoea 
- No wheezing
- central trachea
- vesicular breath sounds 
-Bilateral basal crepts
ABDOMEN
- scaphoid shaped abdomen 
- No tenderness
- No palpable mass
- non palpable liver and spleen

CNS
- conscious and coherent
- normal speech

Diagnosis - patient was diagnosed as hypertensive.

Medication - tab.telma 20 mg/po/of.


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