VERY SIMPLE KINDERGARTEN REPORT Made in my clerkship @@

1. Case report-
A 53 y/o female
with hypertension
clerk C13 吳易儒

2. 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

3. Chief complaint
Leg varicose vein

4. 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

5. 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

6. Social history
no smoking, alcohol drinking or
betalnuts chewing

7. Family history
● father and younger brother has lung
cancer
● old brother has DM

8. 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

9. 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)

10. Image-CT 2013-09-09
● one 4mm faint
GGO nodule in RLL
● no remarkable
change compared
with 2013-01-21

11. Image-CT 2013-09-09
● one tiny faint
nodule in LLL
● no remarkable
change compared
with 2013-01-21

12. Diagnosis
●pre-hypertension under medical
control
●hyperlipidemia
●bilateral lower lung GGO
->(5mm in RLL, fibrotic change in LLL)
found in 2012

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

14. Thanks