University of Medicine (1) Yangon

Community Medicine Program

 
 
 
 
Community Oriented Case Presentation
Medicine - Hypertension

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 Presented by

House Officers of UM (1)

Public Health Field Training
1st posting 2nd Group (20.1.2020 - 3.2.2020)

Contributors

• HS. Dr. Inkyin Tun (Leader)

• HS. Dr. Thaw Hnin San (Presenter)
• HS. Dr. Phyu Phyu Kyaw
• HS. Dr. Thet Htar Tin
• HS. Dr. Aye Eindra Aung
• HS. Dr. Aye Pyae Zaw
• HS. Dr. Thin Htet Aung 2
 History taking
Personal Identification

• Name – U MS
• Age – 75 years
• Gender – Male
• Marital status – Widower
• Race & Religion – Burmese , Buddhist
• Address – GE , Mhaw Bi Township
• Occupation – Dependent ( Retired )
• Date & Time of Admission – 22.1.2020 (6AM)
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Chief complaint

• Severe headache for 1 day

• Blurring of vision for 1 day

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History of Present Illness

• had heavy meal with salty diet on previous night.

• went to bed with light dizziness.
• woke up suddenly at 4AM due to severe headache.
• Headache is sudden onset, throbbing in character and continuous.
• took analgesics but was not relieved.
• associated with sweating, blurred vision, palpitation and cold and
clammy extremities.
• not associated with loss of consciousness, weakness of limbs, fits, and
projectile vomiting.

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• On admission, the blood pressure was 180/100 mmHg.
• treated with mannyl.
• At 9am, blood pressure was 120/80 mmHg
• no history suggestive of chronic complications such as heart failure,
chronic kidney disease and stroke.

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System Review

• CVS – no history of chest pain, dyspnea, orthopnea or edema.

– palpitation (+)
• Respiratory – no history of cough, haemoptysis, dyspnea
• CNS – no history of seizures, loss of consciousness and
projectile vomiting
• – dizziness, headache, blurred vision (+)
• GI – no history of constipation, diarrhoea, vomiting,
abdominal pain
• Musculoskeletal – no history of joint pain, back pain or chronic fatigue
• Renal – no oliguria, dysuria or high colour urine
• Endocrine – no suggestive history 7
Past Medical History
• Malaria history 30 years ago
• He was treated at Mogok Hospital for 9 days.
• No history of heart disease, renal disease, asthma.
 
Past Surgical History
• No past surgical history

Drug History
• Had traditional medicine (Yote Pyo) x 10years
• No known drug allergy
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Personal History
• History of alcohol drinking x 25years
• given up 20years ago.
• History of smoking x 50years.
• Smoking of cigarette and phat kyann.
• 1 cigarette per day
• Pack year = no. of cigarette per day x no. of smoking years
20
= 1/20 x 50
= 2.5
• History of betel chewing for 5years
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Diet History
• prefers salty and fatty meal.
• likes pork, Nga-Pi and dried fish.

Family History
• No history of Hypertension, DM, Heart diseases
 
Social History
• Nuclear type.
• 2 children ( son and daughter)
• Now, he lives with his daughter.
• Financially stable, supported by his children
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 Physical Examination

General Examination
• He is alert and well-oriented.
• GCS – 15/15
• Not dyspnoeic ,not orthopnoeic
• Afebrile
• No pallor, no jaundice.
• No corneal arcus , no xanthelasma
• Teeth and gum are not healthy with betel staining.
• No tonsillar enlargement
• No visible neck gland enlargement.
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Upper limb
• No clubbing
• Nicotine staining (+)
• No pallor
• No cyanosis
• No muscle wasting
• No tendon xanthoma

Lower limb
• No clubbing
• No cyanosis
• No bilateral pitting oedema
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Cardiovascular Examination

• JVP – not raised

• BP – 120/80mmHg
• Pulse rate- 80/min, regular rhythm, moderate volume, equal on both
sides, no arterial thickening, no radio-femoral delay.
• There is no special character.
• Peripheral pulsations are intact.
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Precordial Examination

• No chest wall deformity

• No scar, no visible pulsation
• Apex beat – left 5th intercostal space, within the midclavicular line
• Auscultation – normal 1st and 2nd heart sound, no other added sound

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Respiratory Examination

• Palpation – chest wall expansion – normal

• Percussion – normal percussion note all over the lung fields
• Auscultation – vesicular breath sound, no other added sounds
air entry equal on both sides.
• Vocal resonance and vocal fremitus are normal.

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Abdominal Examination
Inspection
• Abdomen is soft and not distended.
• Abdomen moves with respiration.
• Hernia orifices are intact.
Palpation
• On light palpation, abdomen is soft, no guarding, no rigidity and no tenderness. Temperature is
normal. There is no palpable mass
• On deep palpation, Liver and spleen are not palpable. Kidneys are not ballotable.
Percussion
• No free fluid is detected.
Auscultation
• Normal bowel sound is heard. 16
CNS Examination
Right Left
 
• Tone Uppernormal normal
Lower normal normal

• Power Upper5/55/5
Lower 5/5 5/5
 
• Reflex All* normal normal
 
• Clonus (-) (-)

All* = Biceps , triceps, superficial, knee jerk, ankle jerk 17

Provisional Diagnosis

• 75 years old man with essential hypertension with no other

complication.

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Points for diagnosis

• Old age
• dizziness, blurred vision
• Prefer to salty diet
• history of taking traditional medicine
• blood pressure – 180/100 mmHg
• smoking history (+)

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DDx

• Hypertensive encephalopathy
• Stroke
• Subarachnoid haemorrhage
• Transient ischemic attack
• Injury to head

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Investigations done
• RBS – 110mg%
• ECG – Cardiac axis is normal
– AV block

Suggestive Investigations
– lipid profile, urine RE, CXR, HbA1c, urea, electrolyte, creatinine

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Treatment given at hospital

• IV Mannyl 1 bot stat

• PO Nifedipine 20mg bd
• PO Cinnarazine1 tds
• PO B1+B6+B12 1 bd
• PO Gelmeg 1 tds

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Problem Analysis

• Poor health knowledge instead of good financial status

• Negligence
• Sedentary life style
• Smoking history
• Salty diet

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 Fish bone Diagram of Problem analysis

Smoking
Old Age
Financial Burden
Psychosocial
Prefer salty diet Hypertension Hospitalization Problem
Family Burden

Sedentary
lifestyle Poor Health
Knowledge

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Problem Solving
Individual Level
• Give health education about the nature and consequences of hypertension.
• Explain that hypertension is not temporary disease and that there is no
absolute care and only treated by controlling BP and is not controlled
accordingly and it may lead to fatal consequences such as coronary heart
disease , stroke , blindness, renal failure and eventually death.
• Give health education about importance of regular blood pressure
monitoring
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• Explain that antihypertensives are not meant to be taken only when BP is high
which is a common misbelief in community and antihypertensives must be taken
lifelong
• Explain the side effects of antihypertensives and importance of lifestyle
modification concerning diet.
• We suggested him to reduce salt intake in daily practice
• We suggested him to avoid physical inactivity
• We also explained him about the habits of smoking which can worsen the course 26
Family Level

• As he lives with his daughter, we suggested his daughter to encourage

him to take antihypertensives regularly and on time.
• To do regular followup and regular BP monitoring at nearby clinic.
• We have explained the patient about the nature and the consequences of
the disease

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Community Level

• Promotion of community awareness about hypertension and its danger

• Health education to public about the disease nature, causes, complications, prevention
and control via pamphlets, radio, newspapers, journals, and televisions in order to get
early diagnosis and prompt treatment.
• Encourage the community about the healthy lifestyle and to take well-balanced diet to
improve status of community.
• Organization of well-organized health services within community
• Initiation of focus group discussion about the effects of smoking in social life.

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National Level

• Improving living standards of community by promoting health educational

status and job opportunities if possible
• Allocating of human resources and budgets to projects about hypertension.
• Strengthen health facilities (clinic, hospitals, and drug supply) by creation of
easy accessibility to the health services and availability of health services
• Improving collaboration between NGOs, INGOs, and government officials,
in control of hypertension and risk reducing programs

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• Developing comprehensive nation policy and plan for prevention and control of
major NCDs.
• Establishing high-level national multi-sectorial mechanisms for planning, guiding
and monitoring,-Implementing cost-effective approaches for early detection of
major NCDs.
• Strengthening on human resources for better case management
• Epidemiological surveillance(data analysis and reporting the cases of hypertension)

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• THANK FOR YOUR KIND ATTENTION

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