60 year old male c/c severe headche

 

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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 history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 60 year old male came to opd with severe headache

Chief complaints 

Severe headache since 5 days

Hopi

Patient was apparently asymptomatic 5 days back then he developed headache , so he visited local RMP and diagnosed with hypertension ( 160/100) then he had local medicines. The next day BP was high so he was asked to refer to higher centre.yesterday his BP was 200/110 when he came to our hospital.

Neck movements are restricted since 5 days

No h/o fever

No h/o vomitings 

Past history 

No h/o DM,CAD, epilepsy,thyroid,asthma,TB

History of fracture to right arm

Daily routine

 Patient gets up at 4 am and does he daily chores ,have breakfast at 9 am (rice , vegetable curry,tea) and goes to his daily labour work.he ll have his lunch at work and comes back to home at 5pm .he ll have alcohol(. 90ml)daily night and have his dinner at 9pm and sleeps at 10pm.

Personal history 

Appetite: normal

Diet:mixed

Bowel: normal 

Bladder:decreased frequency 

Addictions: alcohol and beedi(daily 5 )

General examination 

Patient is conscious,coherent,cooperative ,well oriented to time, place and person.

Pallor: absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy:absent

Pedal edema: absent

Vitals

BP: 180/100

PR:70bpm

Temp: afebrile

RR: 16

Systemic examination 

CVS - S1 S2 heard

R/S - inspection

No scars present

Trachea- central

Auscultation:

Vesicular breath sounds heard

P/A - 

Inspection -  Umbilicus inverted , No abdominal distention,scars and swelling.

PALPATION:   Soft, non tender, no organo megaly.

AUSCULTATION:

BOWEL SOUNDS HEARD

CNS - NO focal deficit found.

No meningeal signs 

Investigations 

ECG 

USG 

Provisional diagnosis

Hypertensive urgency