Case #1: HYPERTENSION 

  
This is a case of M.C., 42-years-old, female, right-handed, single, from Pandacan, Manila, Roman
Catholic, who came in due to headache and general body weakness. 
  
Date interviewed: July 28, 2020 at 11;30am 
  
7-months PTC -> patient had intermittent headache, on parieto-occipital area, bilateral, squeezing in
character, radiating to the nape, 5/10 in severity, occurs usually after a stressful work-related activity.
No chest pain, no vomiting, no blurring of vision, no numbness, no weakness, no loss of consciousness,
no seizures. She consulted their company clinic to check her blood pressure and noted to be 150/100.
She was only given Clonidine 75mcg, 1 tablet sublingual and Paracetamol 500mg/tab for pain which
relieved temporarily her symptom. She was advised BP monitoring and regularly take her
medications. She reported that she has been taking many medications for her hypertension in the past,
but stopped taking them because of the side effects. She could not recall the names of the medications.
Currently she is taking 100 mg/day atenolol and 12.5 mg/day hydrochlorothiazide (HCTZ), which she
admits to taking irregularly because “... they bother me, and I forget to renew my prescription.” Despite
this antihypertensive regimen, her blood pressure remains elevated, ranging from 150 to 155/110 to
114 mm Hg. 
  
In the interim there was persistence of occasional headache and nausea. BP monitoring was noted to be
at 150/90-100s. Patient only self-medicated with Paracetamol which afforded temporary relief of the
symptoms. 
  
Until 3 hours PTC -> while doing her chores, she experienced worst headache, heavy in character,
bilateral temporoparietooccipital area radiating to her nape, continuous associated with one episode of
vomiting of previously ingested food, blurring of vision, generalized weakness, no numbness, no slurring
of speech, no loss of consciousness. She was immediately brought to the emergency room by her
common-law husband and BP was noted to be at 190/115. 
  
PMHx:  FHx  PSHx 
a 7-year history of hypertension first (+) HTN – paternal and maternal  Smoker – 10 pack-years
diagnosed during her last pregnancy (+) Diabetic – maternal, died at 56 stopped 5 months ago 
with poor compliance to medications as years of age from hypertension- Occasional alcoholic
mentioned  related cardiovascular disease (CVD)  beverage drinker ~ 1-2
Not known Diabetes mellitus  No Bronchial asthma  bottles beer per
No Bronchial asthma  No COPD  occasion 
No PTB treatment  No thyroid, kidney, liver disease  Has no time to do other
No known thyroid, liver, kidney disease     activities 
No known allergies  OB Hx:  Fond of eating in fast
No previous hospitalization nor LMP – July 2, 2020  food and instant ramen  
surgeries except Cesarean Section  M- 13 years old  Denies illicit drug use 
nor trauma  I- regular  Works as call center
D- 4-6 days  agent 
A- 3-4 pads/day not fully soaked    
S- dysmenorrhea and headache  Sexual Hx: 
G2P2 (2002)  Had 1st coitus at 20 years
 1st child- no fetomaternal of age, only 1 sexual
complication- NSD- 2012  partner, previously used
2nd child- no fetomaternal OCP 
complication except pre-eclampsia- LT
CS -2013 
  
  
ROS: 
No weight gain nor loss, no fever, no chills 
No ear pain, no ear discharge, no nasal discharge nor congestion, no throat pain, no dysphagia 
No cough, no difficulty of breathing, no hemoptysis 
No chest pain, no palpitation, no orthopnea, no PND, no edema 
No abdominal pain, no hematemesis, no change in bowel habits, no melena, no hematochezia 
No dysuria, no hematuria, no urgency, no frequency, no oliguria nor anuria 
No polyuria, no polydipsia, no heat nor cold intolerance 
No arthralgia, no myalgia, no tremor, no anhedonia, no seizure 
  
PE: 
Conscious, coherent, oriented to place, person, and time, well kempt, wheel-chair borne, able to sit with
assistance 
BP-190/110 in the right arm sitting position and 185/110 in the left arm sitting position, CR-95bpm, RR-
20cpm, Temp- 36.9C at 7am, O2 saturation-98% at room air 
Height- 5’4”   Weight- 65 kg 
Evenly distributed hair, normocephalic, anicteric sclera, pink palpebral conjunctiva, clear both cornea,
no nasal discharge/congestion, nasal septum at midline 
No lesions on the pinna, normoset, no tragal tenderness, ear canals are patent, no edema nor erythema,
visualized both cone of light located anterior inferior, intact both tympanic membrane  
With transillumination on both sinuses, no tenderness on frontal and maxillary sinuses, no
tonsillopharyngeal congestion, moist oral mucosa 
Flat neck veins, JVP: 8cm from the RA at 45o, no cervical lymphadenopathy, no carotid bruit 
Symmetrical expansion, no retraction nor use of accessory muscles, no circumoral cyanosis, equal tactile
fremitus posterior lung fields, vesicular breath sounds at periphery, no adventitious breath sound. 
Adynamic precordium, no heaves, lifts, or thrills, PMI at 6th ICS, MCL, 2.5cm in diameter, S1 louder than
S2 at apex, S2 louder at base, distinct heart sound, no murmur 
Flat abdomen, inverted umbilicus, silver striae on the lateral side of both lower quadrants, normoactive
bowel sounds, no bruit at the epigastric area and level of umbilicus, percussion not done due to
patient’s discomfort, no tenderness, no masses on palpation 
No edema, no peripheral cyanosis, no clubbing, no varicosities, pulses on both brachial, radial, posterior
tibial and dorsalis pedis are grade 2+, CRT <2sec, equal range of motion of all extremities both active and
passive movements 
  
Neurologic exam:  Cranial Nerve Examination: 
Oriented to time, place, I – able to determine the smell of coffee on either side 
and person  II – VA: OU- 20/25, pinhole OU: 20/25 
Calculation not done   Fundoscopy: both exhibit ROR, clear media, clear disc ratio (0:3), noted
Able to name 3 objects arterio-venous nicking, disc margins are distinct, no exudate, no
and remember them  hemorrhages 
Intact speech content  II, III- eyes accommodate and converge on near object, pupils 3->2mm OU,
both reactive to light on direct and indirect stimulation 
III- no ptosis 
III, IV, VI –  has conjugate gaze both horizontal and vertical, no nystagmus 
V – able to differentiate sharp and blunted object on the forehead, maxillary
and mandibular area on both sides, able to clench his teeth 
V, VII- (+) intact corneal reflex bilateral 
VII – no facial asymmetry 
VIII – intact gross hearing 
IX, X – good gag reflex, able to articulate clearly 
X- uvula is at midline upon saying “ah”  
XI – R = L shoulder shrug resistance 
XII – tongue is at midline on protrusion,  no fasciculation 
  
Manual Muscle (Motor) Testing                 
- symmetric muscle bulk of the major muscle groups on both extremities, patient is able to sit with
assistance, no rigidity nor flaccidity                                         
-all activities of major muscle groups on both upper and lower extremities are grade 3/5, 
  
Sensory Testing 
The pain sensation on the both side of the upper and lower extremities, trunk and abdomen are graded
as 100%, vibration sense on both distal joints of extremities are equal 
  
Cerebellar Testing 
No dysdiadochokinesia on both sides 
  
No nuchal rigidity, no Kernig’s, no Brudzinski, no Babinski reflex 
 
STUDY GUIDE QUESTIONS: 
1. How would you describe the completeness of the data presented? 
2. How would you improve the data to supplement your working diagnosis? 
3. Identify the problems presented in the case. 
4. Discuss appropriate differential diagnoses ( at least 3) which describe the case. 
5. Enumerate the diagnostic examinations needed for the case. 
6. Explain the rationale of the diagnostic examinations necessary for the case. 
7. Interpret the results of each requested diagnostic examinations and correlate it with case. 
8. Formulate a working impression of the case. 
9. Elucidate both pharmacologic and non-pharmacologic up-to-date standard of care management 
appropriate for the case. 
10. Create a concept map of the pathophysiological bases of the manifestations of the case.

Laboratory examination results

CBC: Hgb- 145 g/L Hct- 43% RBC- 5 x 109/L WBC- 10.0 x 109/L
Platelet count- 250 x109/L Neutrophils- 60% Lymphocytes- 25% Eosinophils- 4%

Urinalysis: color – yellow turbidity- clear pH- 6.0 specific gravity- 1.015
Sugar- none Protein- trace RBC – 1-3/hpf WBC- 0-2/hpf Bacteria- rare Cast- none
Epithelial cell- occasional

Blood chemistry:
BUN- 10 mg/dL
Creatinine- 0.90 mg/dL
Serum albumin – 3.5 g/dL
Uric acid- 7.5mg/dL
Lipid profile: Total Cholesterol – 268 mg/dL
HDL – 40 mg/dL
Trigylcerides- 230 mg/dL
LDL- 155mg/dL
Serum Ca++ - 9.8mg/dL
Serum Na+ - 138 mEq/L
Serum K+ - 3.4mEq/L
FBS – 105mg/dL