HTN

 34 YEAR  OLD MALE MASON BY OCCUPATION CAME TO THE OPD WITH 

C/O Blurring of vision RE greater than LE since 3 yrs not associated with headache ,nausea , vomiting


Patient was apparently assymptomatic 3 yrs back ,while he was doing his work complained of giddiness and fell( black outs)non postural,not associated with nausea, vomitings,vertigo,tinnitus,earfull ness ,he was taken to a local hospital and was diagnosed with HIGH BLOOD PRESSURE  ( used medication , unknown) for over 2  1/2 yrs 


C/O slurring of speech since 1 year ( progressive) 


C/O body pains since 1 year 


H/O giddiness 1 week back taken to local hospital ,was on medication ( unknown) 


No C/O chest pain , palpitations, shortness of breath ,pedal edema 


K/C/O HTN since 3 yrs (on past atenolol 50mg ,nicardia 10 mg,telma 40 mg)


Not a K/C/O DM,ASTHMA, EPILEPSY,TB


He is alcoholic (90ml /day)and smoker ( 2 per day)since 10 yrs 


No significant family history 


Vitals on admission:

BP: 270/140 mm hg 

 given Nicardia 20 MG and measured bp after 20 mins still the Bp was 270/140 mm hg 

PR : 90bpm

RR: 18 cpm


All the peripheral pulses  present 

Ankle brachial index > 1.25 

Renal bruit present

BP:

         RT          LT

UL  160/100   170/100

LL  200         200


Cvs : s1s2 + no murmurs

RS : Nvbs +

P/a : soft nontender

CNS : 

1) HMF - INTACT 


2)MOTOR SYSTEM : 

                      Right          Left

Bulk: 

Inspection.      N.              N

Palpation.        N.             N

Tone: 

UL.                  N.               N

LL.                    N.             N


Upper Limb:

Shoulder: Flexion 5/5.    5/5

Extension.             5/5.     5/5 

Abduction:            5/5.      5/5 

Adduction:            5/5.     5/5 

Elbow: 

Flexion (biceps)    5/5.    5/5 

Extension (triceps)  5/5. 5/5

Lower Limb:

Ilio psoas.                5/5.   5/5

Gluteus max.           5/5   5/5

Adductor femoris.   5/5  5/5

Hamstrings.             5/5   5/5

Quadriceps.             5/5   5/5

Tibialis ant.             5/5     5/5

Tibialis post.           5/5.    5/5

Ex. Digitorum L.     5/5.    5/5 

Fl. Digitorum L.      4/5.    4/5

Ex. Hallucis L.        4/5.    4/5

Deep tendon reflexes:

Biceps:                     +2        +2

Triceps:                   +1      +1

Supinator:               +2        +2

Knee:                       +3          +3

Ankle:                      +3         +3

Plantar:                  extensor        flexor


Sensory:

STT: Crude touch. +          +

Pain.                        +         +

Temp.                      +         +

Post. Dorsal

Fine touch.            present

Vibration.                +       +

Position.                 +      +


Cranial nerves : 

II - Blurring if vision present - Rt side > left side.

Visual acuity -  Right side - only PL/PR present.

and hand movements perceived . Cant count fingers.

Left side - Counting fingers 3 m present.


III,IV,VI - Extra-ocular movements intact


ii)                  Pupil – Size - 4 mm - B/L NSRL


iii)                Direct Light Reflex - Present.


V - i) Sensory -over face intact


ii) Motor – masseter, temporalis, pterygoids 


iii) Reflex


a.       Corneal Reflex - present


b.      Conjunctival Reflex - present


c.     Jaw jerk - present.

VII - Slight deviation of mouth to left side .

IX ,X- Uvula deviated to right side .

Gag reflex intact.


XI, -normal

XII - no deviation of tongue .


CEREBELLUM : Heel knee test - normal

Finger nose couldn't be performed because of blurring of vision .

Horizontal Nystagmus present . Fast component to left side .

Couldn't perform Tandem gait .


Bp - Unequal in both arms .

All peripheral pulses felt and no asymmetry noted.


Cause for his  renal artery stenosis?

could it be ? takayasu arteritis .

ACR criteria - for Takayasu arteritis .(in out pt)


1)Age of 40 years or younger at disease onset - present.

2)Claudication of the extremities - absent 

3)Decreased pulsation of one or both brachial arteries - absent ( equal on both sides )

4)Difference of at least 10 mm Hg in systolic blood pressure between arms - Present .

5) Bruit over one or both subclavian arteries or the abdominal aorta - absent over subclavian. heard over renal artery .

6)Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the upper or lower extremities - 

We dont have evidence yet . have to get CT ANGIOGRAM done .


















Diagnosis : HYPERTENSION SECONDARY TO RIGHT RENAL ARTERY STENOSIS WITH

GRADE IV HYPERTENSIVE RETINOPATHY WITH

RENAL ARTERY STENOSIS SECONDARY TO ? VASCULITIS ? TAKAYASU ARTERITIS WITH

LVH WITH RIGHT FACIAL PALSY WITH SLURRED SPEECH WITH DENGUE FEVER NS1 POSITIVE

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