Harvey Hoya Ihuman
History and Physical Exam – Harvey Hoya Ihuman
How can I help you today?
Do you have any other symptoms or concerns that we can discuss?
When did your high blood pressure start?
How severe is your high blood pressure?
Have you gained weight?
When did your headache start?
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Harvey Hoya Ihuman- Key Findings and Problem Statement
Case: Key Findings
Key Finding
Elevated BP
Headaches
Daytime somnolence and fatigue
Smoker
Overweight status
Hypertensive retinopathy – AV Nicking
Laterally displaced PMI
Snoring, awoken by wife for breathing problem
NSAID use
Poor eating habits
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Harvey Hoya Ihuman Case: Key Findings Feedback
The medical problem list you have compiled should be a list that includes everything that is out of the ordinary about this patient, even when it is not a “problem” in the true sense of the word.
Next, this list should be examined in an attempt to group those findings that are related to the chief complaint or MSAP or that tend to be found together in specific disease states. This is the first step in developing and ranking your differential diagnosis.
In this case, HT stands out as the most significant active problem (MSAP). It is central to your identifying the other findings belonging in 1 or more of the following categories
•Risk factors
• Comorbidities
•End-organ change/damage
Whereas many of the problems are seemingly easy to categorize in this manner, others may not be so straightforward. For example: HTN-related headaches typically occur in the morning and are felt at the back of the head. However, morning headaches and daytime somnolence are also consequences of sleep apnea, which may be present as a comorbidity and/or may be the cause of the hypertension.
If there is presence of a renal bruit, it could suggest a specific etiology for HT, and should prompt you to consider the various causes of secondary HT.
Case: Problem Statement
The patient is a 57-year-old overweight Hispanic construction worker who presents for evaluation of an elevated blood-pressure reading at a recent local health fair. He reports intermittent mild headaches, and interrupted sleep with snoring Physical examination is notable BP 172/94 L and 178/98 R; laterally displaced PM; and, funduscopic findings of A-V nicking. Was told he had elevated BP in the past, but took no action. FH is positive for hypertension and related complications.
Case: Management Plan – Harvey Hoya Ihuman
Management Plan
Key elements of the patient’s treatment plan will include the following
1. HTN
• His BP goal is SBP=120 and DBP 80 mm Hg since he is less than 60 y/o
• Medication selection: he is nonblack (Hispanic) so the recommendation by the JNC 2013 is initiate thiazide-type diuretic or ACEI or ARB or CCB alone or in combination
–Start HCTZ 25 mg po Q D x 1 week, F/U 2 weeks, if still hypertensive, consider increasing to BID or adding ACEI (Lisinopril) 10 mg PO Q D to achieve BP goals stated above.
• Arrange for home BP monitoring
• Obtain lipid panel and HgA1c as baseline measurements
• Nutritional consultation for weight loss
Sleep Apnea
• Refer for CAP assessment and fitting (sleep apnea device)
• Counsel patient regarding lifestyle modification – alcohol, weight reduction, smoking
Patient lifestyle counselling:
• General dietary recommendations to reduce fats and salt and increase foods with potassium . Weight reduction – recommend a loss of 13 Is
• Avoidance of NSAIDs – to minimize renal injury
• Smoking cessation – to reduce risk of atherosclerosis
•BP assessment at 2 weeks, with regular follow-up thereafter
Click here for a Harvey Hoya Ihuman hypertension treatment plan.
