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Case report-
A 53 y/o female
with hypertension
clerk C13 吳易儒
Basic data
姓名: 周OO
年齡/性別: 53 y/o female
職業: retired form 金融業
婚姻: married
種族: 閩南
Chief complaint
Leg varicose vein
Present illness
● 53 y/o retired female
●has been diagnosed as hypertension for 5
years
●regularly under medical control
(...
Medical history
● pre-hypertension since 2009
● bilateral lower lung GGO(5mm in
RLL, tiny faint nodule in LLL) found in
20...
Social history
no smoking, alcohol drinking or
betalnuts chewing
Family history
● father and younger brother has lung
cancer
● old brother has DM
Physical examination
●BP: 128/80 mm Hg, PR: 67 bpm
●no carotid bruit, enlarged thyroid
●clear breathing sound
●RHB, no par...
Lab data
TSH 2.8 uIU/mL (0.25-4)
Creatinine 0.73 mg/dL (0.5-1.3)
GFR 83* mL/min/1.73㎡ (>90)
Uric Acid 3.4 mg/dL (女:1.9-6.5...
Image-CT 2013-09-09
● one 4mm faint
GGO nodule in RLL
● no remarkable
change compared
with 2013-01-21
Image-CT 2013-09-09
● one tiny faint
nodule in LLL
● no remarkable
change compared
with 2013-01-21
Diagnosis
●pre-hypertension under medical
control
●hyperlipidemia
●bilateral lower lung GGO
->(5mm in RLL, fibrotic change...
Treatment
● suggest self-monitoring blood
pressure at home
● under Co-Diovan(Valsartan+
Hydrochlorothiazide) treatment
● s...
Thanks
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Case report- Hypertension

VERY SIMPLE KINDERGARTEN REPORT
Made in my clerkship @@

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Case report- Hypertension

  1. 1. Case report- A 53 y/o female with hypertension clerk C13 吳易儒
  2. 2. Basic data 姓名: 周OO 年齡/性別: 53 y/o female 職業: retired form 金融業 婚姻: married 種族: 閩南
  3. 3. Chief complaint Leg varicose vein
  4. 4. Present illness ● 53 y/o retired female ●has been diagnosed as hypertension for 5 years ●regularly under medical control (ARB+Thiazide) ●self monitor blood pressure about once a week
  5. 5. Medical history ● pre-hypertension since 2009 ● bilateral lower lung GGO(5mm in RLL, tiny faint nodule in LLL) found in 2012 ● epidermal cyst over pre-pubic area, s/p excision
  6. 6. Social history no smoking, alcohol drinking or betalnuts chewing
  7. 7. Family history ● father and younger brother has lung cancer ● old brother has DM
  8. 8. Physical examination ●BP: 128/80 mm Hg, PR: 67 bpm ●no carotid bruit, enlarged thyroid ●clear breathing sound ●RHB, no paroxysmal nocturnal dyspnea ●legs varicose vein, no edema
  9. 9. Lab data TSH 2.8 uIU/mL (0.25-4) Creatinine 0.73 mg/dL (0.5-1.3) GFR 83* mL/min/1.73㎡ (>90) Uric Acid 3.4 mg/dL (女:1.9-6.5) Cholesterol Total 214 * mg/dL (130-200) Triglyceride(TG) 60 mg/dL (女:35-165) Calcium(Ca) 9.4 mg/dL (8.5-10.5) Sodium(Na) 137 mmol/L (135-147) HDL-Cholesterol 58.0 mg/dL (女:35-85) LDL 144.00 CHOL/HDL-C 3.69 Glucose AC 100 mg/dL (70-110) -> TC/TG/HDL: 155/43/46/100 (2009-1-23) -> TC/TG: 210/35 (2010-6-8) -> TC/TG/HDL: 214/60/58/144 (2013-3-9)
  10. 10. Image-CT 2013-09-09 ● one 4mm faint GGO nodule in RLL ● no remarkable change compared with 2013-01-21
  11. 11. Image-CT 2013-09-09 ● one tiny faint nodule in LLL ● no remarkable change compared with 2013-01-21
  12. 12. Diagnosis ●pre-hypertension under medical control ●hyperlipidemia ●bilateral lower lung GGO ->(5mm in RLL, fibrotic change in LLL) found in 2012
  13. 13. Treatment ● suggest self-monitoring blood pressure at home ● under Co-Diovan(Valsartan+ Hydrochlorothiazide) treatment ● suggest lift legs to relieve varicose ● keep regularly exercise
  14. 14. Thanks

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