History and Physical Exam – Harvey Hoya iHuman
Greetings! How can I assist you today?
Are there any other symptoms or concerns you’d like to discuss?
When did you first notice your high blood pressure?
How would you describe the severity of your high blood pressure?
Have you experienced any weight gain recently?
Can you recall when your headaches initially began?
Harvey Hoya iHuman – Key Findings and Problem Statement
Case: Key Findings
- Elevated blood pressure
- Headaches
- Daytime somnolence and fatigue
- Smoking habit
- Overweight status
- Hypertensive retinopathy – AV Nicking
- Laterally displaced PMI
- Snoring, awoken by wife due to breathing problems
- NSAID use
- Poor eating habits
Feedback on Key Findings: The medical problem list should encompass everything unusual about the patient, even if not strictly a “problem.” Next, categorize these findings related to the chief complaint or MSAP, grouping those often found together in specific disease states. In this case, Hypertension (HT) stands out as the most significant active problem (MSAP), forming the basis for identifying other related findings.
Consider the following categories for grouping findings:
- Risk factors
- Comorbidities
- End-organ change/damage
Some findings may not be straightforward to categorize. For instance, HTN-related headaches and daytime somnolence may also result from sleep apnea, potentially acting as a comorbidity or causing hypertension. If a renal bruit is present, it could suggest a specific cause for HT, prompting consideration of various secondary HT causes.
Case: Problem Statement The patient, a 57-year-old overweight Hispanic construction worker, seeks evaluation for an elevated blood pressure reading. He reports intermittent mild headaches and disrupted sleep with snoring. Physical examination reveals notable blood pressure readings, laterally displaced PM, and funduscopic findings of A-V nicking. The patient was informed of elevated BP in the past but took no action. Family history is positive for hypertension and related complications.
Case: Management Plan – Harvey Hoya iHuman
Management Plan
- HTN
- BP goal: SBP=120 and DBP 80 mm Hg (since less than 60 y/o)
- Medication: initiate thiazide-type diuretic or ACEI or ARB or CCB alone or in combination (Start HCTZ 25 mg po QD, follow up in 2 weeks, consider adjustments if hypertensive)
- Home BP monitoring
- Baseline lipid panel and HgA1c
- Nutritional consultation for weight loss
- Sleep Apnea
- Refer for CAP assessment and fitting
- Lifestyle modification counseling: alcohol reduction, weight loss, smoking cessation
- General Lifestyle Counseling
- Dietary recommendations: reduce fats and salt, increase potassium-rich foods
- Weight reduction: recommend a loss of 13 lbs
- Avoid NSAIDs to minimize renal injury
- Smoking cessation to reduce atherosclerosis risk
- BP assessment at 2 weeks, with regular follow-up thereafter
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