The document provides a detailed medical evaluation of a 61-year-old female patient diagnosed with hypertensive urgency, presenting with symptoms such as headaches and high blood pressure readings. It includes vital signs, laboratory results, medication lists, and day-wise assessments over four days, detailing changes in her condition and treatment. Goals of therapy focus on maintaining normal blood pressure, improving hemoglobin levels, and patient counseling on dietary and lifestyle changes.

2. DEMOGRAPHIC DETAILS
• DATE OF ADMISSION:26/11/22
• AGE:61 year
• GENDER: Female
• HEIGHT:152cm
• WEIGHT:90kgs
• BMI:39.1

3. SUBJECTIVE EVIDENCE
A 61 year old female has c/o frontal headache , since often
associated with nausea sensation, when checked BP at home
it was 180/90mmhg.Came here for further evaluation.
PAST MEDICAL HISTORY:
.Hypertension,Type 2DM,Hypothyriodism

4. OBJECTIVE EVIDENCE
VITAL SIGNS
DATE DAY 1 DAY 2 DAY 3 DAY 4
BLOOD PRESSURE(mmhg) 160/100 150/80 130/80 120/80
PLUSE RATE(bpm) 93 78 81 81
RESPIRATORY RATE (/min) 20 20 20 10
TEMPERATURE(F) 98.2 98.2 98.6 98.6
SPO2 97 98 98 98

5. BIOCHEMISTRY REPORT
PARAMETER
SODIUM (135-146 meq/l) 130
POTASSIUM (3.5-5.1 meq/l) 4.5
CHLORIDE (95-105 meq/l) 97
RBS(<160mg/dl) 233
SERUMCREATININE (0.5-1.5 mg/dl) 0.7
BLOOD UREA (10-50 mg/dl) 25

6. COMPLETE URINE EXAMINATION
• COLOUR: Pale yellow
• APPEARANCE: Clear
• QUANTITY:20ml
• PH:6.5
• SPECIFIC GRAVITY:1.010
• EPITHELIAL CELLS(1-2):4-5
• ECG REPORT:DILATERAL LA
• GRADE II LV DIASTOLIC DYSFUNCTION
• TRIVIAL MR,MODERATETR/MILDTO MODERATE PH
• N CLOT/NO PERICARDIAL EFFUSION

7. COMPLETE BLOOD PICTURE
DATE DAY 1 DAY 2
HB (11-16.5) 11.7 10.5
PCV(35-50 g%) 36 34
RBC COUNT (4.5-6.5 ml/m3) 4.5 3.9
WBC COUNT (4000-11000 cells/m3) 14,000 8,400
PLATELETS (1.5-4.0 Lac/m3) 3.4 2.9
NEUTROPHILS (40-75%) 82
LYMPHOCYTES (20-40%) 14
EOSINOPHILS(1-6%) 02
ESR (<20mm 1ST Hr) 38
MCV (80-100F1) 80.9
MCH (26.5-33.5) 25.6
MCHC (31.5-35.0) 31.6
MONOCYTES (2-10%)

8. DATE
TOTAL BILIRUBIN (0.22-1.0 mg/dl) 0.58
DIRECT BILIRUBIN (<2mg/dl) 0.13
SGPT (<45 U/L) 33.6
SGOT ( 5-40 U/L) 29.2
TOTAL PROTEIN (5.5-8 g/dl) 7.3
ALBUMIN (3.5-5g/dl) 4.1
GLOBULIN (2-3.5)A 3.2
ALKALINE PHOSPHATE (30-120 U/L) 117.2
LIVER FUNCTIONTEST

9. ASSESSMENT
From the subjective and objective evidence the patient was
diagnosed with Hypertensive urgency.

10. DAY WISE ASSESSMENT
• DAY 1
• c/o Headache 1day , SOB, associated with Nausea , but no vomiting, patient was
apparently normal 3days back then had continuous high BP
readings(190/110mmHg)-Hypertensive urgency
• k/c/o DM,HTN,Hypothyroid
• RR:20/min
• PR:93/min

11. DAY 2: HTN Urgency
k/c/o-DM, HTN, Hypothyroid
BP PR GRBS TLC Na
150/80mm
Hg
78bpm 227mg/dl 14,000 130

12. Day wise assessment
• DAY 3:HTN uurgency, K /C/O DM,HTN,HYPOTHYROIDISM
• BP-130/80mmHg,no fresh complaints
• Patient is c/c
• DAY 4:HTN Urgency k/c/o DM,HTN,HYPOTHYROIDISM
• BP-120/80mmHg
• PR-81bpm
• HbA1C-7.4%,GRBS-143mg/dl

13. MEDICATION CHART
DRUGNAME GENERIC NAME DOSE &
ROA
FREQUENCY INDICATION DAY 1 DAY 2 DAY 3 DAY
4
TAB
LEVOTHYROXINE
THYRONORM 50mg P/O OD To treat Hypothyroidism    
TABTELMA TELMISARTAN 40mg P/O BD To treat high blood pressure    
TAB MET-XL METOPROLOL 25mg P/O BD Beta blockers-Treat HTN    
TABARKAMINE CLONIDINE 0.1mg P/O TID To treat high blood pressure   
TAB.ATORVA ATORVASTATIN 20mg P/O OD To decrease the amount of
cholesterol in the body[HMG COA
REDUCTASE INHIBITORS
   
TAB. CTD CHLORTHALIDONE 12.5mg P/O OD To treat high blood pressure and
fluid retention
   
TAB. GABAPIN-NT GABAPENTIN 100mg P/O OD To treat restless leg syndrome{or
any discomfort in the legs}
  
TAB. NIFITA METHYLCOBALAMINAND
BIOTIN
100mgP/O OD Vitamin supplement    

14. MEDICATION CHART
DRUGNAME GENERIC NAME DOSE & ROA FREQUENCY INDICATION DAY 1 DAY 2 DAY 3 DAY
4
TAB. ZAPIZ CLONAZEPAM 0.5mg P/O BD To control involuntary muscle
spams
  
TAB. STLOPAM ESCITALOPRAM
OXALATE
10mg P/O OD To treat generalised anxiety
disorder
   
TABALDACTONE SPIRONOLACTONE 25MG(1/2
tablet)
P/O To treat high blood pressure  
INJ LANTUS INSULIN S/C BD To treat DM  
INJ ACTRAPID INSULIN S/C BD To treat DM  
TAB MODAFINIL MODAFINIL 100MG P/O OD To treat narcolepsy 

15. DRUG-DRUG INTERACTION
S.NO DRUG 1 DRUG 2 SEVERITY EFFECT MANAGEMENT
1. CLONAZEPAM ESCITALOPRAM
OXALATE
MINOR CNS Depressant may
enhance the
adverse/toxic effect of
Selective Serotonin
Reuptake Inhibitor.
Specifically, the risk of
psychomotor
impairment may be
enhanced.
No action required
beyond standard
clinical care
measures for the
majority of patients.
Patients taking
multipleCNS
depressant and
those highly
susceptible to
cognitive
impairment may
require additional
monitoring.

16. PLAN
GOALS OFTHERAPY
To maintain normalWBC count
To decrease and maintain BLOOD PRESSUE
To improve Haemoglobin level
To reduce further complications of DM
P

17. PATIENT COUNSELLING
• Reduce High Sodium Intake ( salt) and eat more potassium instead such as spinach bananas and
tomatoes
• Do some aerobic exercise that can help lower BP such as walking and jogging .
• Avoid high carbohydrate intake .
• Take Beets and beet juice (as it contains high in nitrates which help relax blood vessels and may lower
BP)
• Limit saturated and trans fats(E.g.. Fast foods, hot dogs and frozen foods).
• Take medication as prescribe by the physicians.
• Focus on healthy carbohydrates such as beans peas, fat dairy products such as milk and cheese.
• Eat fibre rich foods(vegetables, broccoli, aavocados, nuts,Whole grains) to control blood sugar levels.

18. REFERENCE:
• www.Medscape.com
• www.Lexicomp.com

19. THANK YOU