57 year old female patient with throat pain since 1 week

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

A 57yr old female patient  resident of marpaka daily worker by occupation came to ent opd with 

Chief Complaints :- throat pain since 7 days

History of presenting illness:-

Patient  was apparently asymptomatic 5years ago then she developed lower back pain which is non radiating continuous type for which she went to local hospital and they said she is suffering from kidney problem and got treated but not completely resolved due to irregular intake of medicine .

There is history of facial puffiness and bilateral  swelling in foot which is upto ankle since 2 months.History of 2 episodes of dialysis were done .

History of throat pain since 7 days which is insidious in onset and nonprofressive in nature .On examination she was found to have bp of about 190/110 mmHg soon she was referred to GM opd .

No h/o headache fever blurring of vision 

Past history:-

Hysterectomy done 10 years ago 

Known case of hypertension since 3 years 

No h/o asthma diabetes tuberculosis epilepsy 

Personal history :-

Diet :- mixed

Sleep :- adequate

Bowel and bladder moments:- regular 

No addictions 

Appetite : normal 

Family history;-

No significant family history

Treatment history:-

Anti hypertensive drugs since 3 years (unknown )

General examination :-

 Patient is conscious coherent and cooperative well oriented with time place and person moderately built and well nourished 

No pallor 

No icterus

No cyanosis

No clubbing 

No lymphadenopathy

Pedal edema present 

Vitals :-

Afebrile

BP:- 160/90 mm hg 

PR:- 85bpm

RR:- 17 cpm

HR:-100bpm

Systemic Examination:-

CVS:

Auscultation :

 S1S2 heard no murmurs 

Normal regular rhythm 

Jvp not seen

Palpation:-

Apex beat at 5th intercoastal space 

CNS : no focal neurological deficits

RS: bilateral normal vesicular sounds heard 

Per abdomen :soft and non tender 

Provisional diagnosis:-

Hypertensive urgency 

Investigations :-

Fundus examination :- normal 

Echocardiograph

3/12/22

4/12/22

Complete blood picture 

Blood Urea :

Complete Urine Examination 

Liver Functional Test:

Serum Creatinine 

Serum Electrolytes 

Treatment:-

3/12/22:- 

Nifidipine 20mg PO 

Monitor vital

Inform sos 

4/12/22:-

Fluid restriction

-Salt restriction

-Tab.Shelcal 500 once daily

-Tab.Lasix 40mg PO once daily

-Tab.Cilnidipine 10mg PO once daily

-Monitor vitals