Emergency Room Medical Report

NATIONAL UNIVERSITY OF
CHIMBORAZO
Faculty of Health Sciences Medicine
Medical English
Semester: Eighth “A”
Members:
• Delfa Castillo
• Lissette Chamba
• Nicole Hidalgo
• Angie Reyes TEACHER:
• Valeria Riera Dra. LUCILA DE LA CALLE
• Grace Tixi
TOPIC: EMERGENCY ROOM MEDICAL REPORT

01 INTRODUCTION
INTRODUCTION
Hypertensive crisis
It is that acute elevation of the BP that

motivates an urgent medical consultation,
with figures of diastolic BP above 120 mmHg
and / or systolic BP above 210 mmHg.
Hypertensive emergency Hypertensive urgency

EPIDEMIOLOGY
High blood pressure is the

most common chronic disease
in Western countries,
affecting more than 20% of its
adult population.
This disease is more frequent

in patients of 40 and 50 years.
CLINIC
Patient assessment
Background: You should ask

yourself about the drugs that
the patient usually takes for
any ailment, looking for the
cause of the crisis.
In the current disease we

must focus, above all, on
looking for the affection of the
target organs.
Physical exploration
• Taking blood pressure

• Cardiopulmonary auscultation and data on the
peripheral pulse.
• Abdominal examination
• Limbs
• Neurological examination
02 EMERGENCY ROOM
MEDICAL REPORT
CHIEF COMPLAINT
• Headache and
dizziness
HYSTORY OF PRESENT ILLNESS
This 24- year-old female presents to the emergency

room referred for out-of-hospital emergency services,
due to symptoms of holocranial headache, dizziness
and presyncope of sudden onset, without language
alteration or limb weakness, loss of sensation or other
focal neurological deficits.
One day before she presents similar episodes of less
intensity with a weekly frequency, She states that
never had tremor, palpitations, dyspnoea, chest pain
or nervousness.
PAST MEDICAL HISTORY
Surgical Alcoholism
history
Pathological Non- pathological Drugs
history history
Acute Does not refer
appendicitis
Feeding 3 times
Not referred per day, Does not refer
unbalanced
Current Allergies
medications
Not referred Not referred

SOCIAL HISTORY
Number of children
0
Property
leased
Economic income
does not refer
Pets
does not refer
Basic services
electricity, wáter, sewerage
REVIEW OF
SYSTEMS
SKELETAL
CADIOVASCULAR GENITOURINARY:
MUSCLE
no heart problems no history of no problems
kidney trouble.
RESPIRATORY DIGESTIVE ENDOCRINE NERVOUS

no problems no change in no problems SYSTEM:
bowel habit as noted in HPI
PHYSICAL
EXAMINATION
1. Vital signs: BP 243/125. Heart rate 90. Resp 15. Temp
36,4. Oxygen saturation 98%
2. Head: normocephalic
3. Eyes: The fundus examination revealed grade II-III
hypertensive retinopathy in the right eye and grade I in
the left eye.
4. Neck and nodes: negative.
5. Chest: clear to percussion and auscultation.
6. Cardiac: normal sounds. No murmur or other sounds.
7. Abdomen: no hepatosplenomegaly, no masses.
8. Neurologic exam: glasgow scale 13/15
SUPPLEMENTARY
TESTS
ANALYTICAL TEST PATIENT VALUE
blood glucose 130 mg/dL
creatinine 0,68 mg/dL
sodium 135 mEq/L
potassium 2,61 mEq/L
baking soda 27,1 mmol/L
Electrocardiogram: sinus rhythm at 80 bpm with voltages
that meet criteria for left ventricular hypertrophy
Chest X-ray: normal

DIAGNOSES
• Vascular hypertension secondary to

stenosis of the right renal artery by
tubular fibromuscular dysplasia
INTERVENTION
A new analytical battery is made

to purify the possible differential
diagnoses, presenting the
following findings:
1) Negative pregnancy test
2) Normal TSH
3) Negative acute phase reactants
4) 24 h proteinuria of 3.4 g
5) Plasma renin and aldosterone
activity 4 times the range of
normal.
• These findings indicate the
performance of abdominal CT in
which there are no alterations in
the adrenal glands and a tubular
stenosis of the right renal artery is
observed in its middle part.
Treatment with losartan and
spironolactone is established. The
patient was discharged to home.
EVOLUTION
REFERENCES
A - Daniel Martin, Roy, E., Cárdenas,

M., Carles, P., & Rodriguez, C.
(Agosto de 2017). Mujer de 22
años con encefalopatia
B Hipertensiva. Rev Esp Casos Clin
Med Intern (RECCMI), 2(2),91-93.
Obtenido de
http://video.grupocto.com/videos
C Especialidades/reccmi/09_2017/
Pdfs/Cas o_10_RECCMI_N_4.pdf

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NATIONAL UNIVERSITY OF

TOPIC: EMERGENCY ROOM MEDICAL REPORT

It is that acute elevation of the BP that

Hypertensive emergency Hypertensive urgency

High blood pressure is the

This disease is more frequent

Background: You should ask

In the current disease we

• Taking blood pressure

This 24- year-old female presents to the emergency

Not referred Not referred

RESPIRATORY DIGESTIVE ENDOCRINE NERVOUS

Chest X-ray: normal

• Vascular hypertension secondary to

A new analytical battery is made

A - Daniel Martin, Roy, E., Cárdenas,

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