Case report- Hypertension

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(ARB+Thiazide)●self monitor blood pressure about once a week

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

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 paroxysmal nocturnal dyspnea●legs varicose vein, no edema

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)

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 in LLL) found in 2012

Treatment

● suggest self-monitoring blood pressure at home● under Co-Diovan(Valsartan+ Hydrochlorothiazide) treatment● suggest lift legs to relieve varicose● keep regularly exercise

Thanks