Harvey Hoya Ihuman
History and Physical Exam – Harvey Hoya i-Human
History of Present Illness:
- How can I help you today?
- Do you have any other symptoms or concerns that we need to discuss?
- When did you first notice your high blood pressure?
- How severe is your high blood pressure?
- Have you experienced any weight gain?
- When did your headache start?
Harvey Hoya i-Human – Key Findings and Problem Statement
Case: Key Findings
- Elevated Blood Pressure
- Headaches
- Daytime Somnolence and Fatigue
- Smoker
- Overweight Status
- Hypertensive Retinopathy (AV Nicking)
- Laterally Displaced PMI (Point of Maximal Impulse)
- Snoring and Sleep Apnea (awoken by wife for breathing problems)
- NSAID Use
- Poor Eating Habits
Harvey Hoya i-Human Case: Key Findings Feedback
Case: Key Findings Feedback
The medical problem list should include all abnormalities in the patient, even if they are not traditionally considered “problems.” Next, this list should be analyzed to group findings related to the chief complaint or the most significant active problem (MSAP) and those commonly found together in specific disease states. This is the first step in developing and ranking your differential diagnosis.
In this case, hypertension (HTN) stands out as the MSAP. It is central to identifying other related findings, which can fall into one or more of the following categories:
- Risk factors
- Comorbidities
- End-organ changes/damage
While some problems are easily categorized, others may be more complex. For example, hypertension-related headaches typically occur in the morning and are felt at the back of the head. However, morning headaches and daytime somnolence can also be due to sleep apnea, which might be a comorbidity or a cause of the hypertension. If a renal bruit is present, it could suggest a specific etiology for HTN and should prompt consideration of various causes of secondary hypertension.
Case: Problem Statement
The patient is a 57-year-old overweight Hispanic construction worker presenting for evaluation of elevated blood pressure noted at a recent health fair. He reports intermittent mild headaches and interrupted sleep with snoring. Physical examination reveals BP readings of 172/94 mm Hg (left) and 178/98 mm Hg (right), a laterally displaced PMI, and funduscopic findings of AV nicking. He has a history of elevated BP but did not take any action. Family history is positive for hypertension and related complications.
Case: Management Plan
Management Plan
Hypertension:
- Blood Pressure Goal: Target SBP = 120 mm Hg and DBP = 80 mm Hg, as the patient is under 60 years old.
- Medication Selection: As a non-black (Hispanic) patient, follow the JNC 2013 recommendation to initiate treatment with a thiazide-type diuretic, ACEI, ARB, or CCB alone or in combination.
- Start with HCTZ 25 mg PO daily for 1 week. Follow up in 2 weeks; if still hypertensive, consider increasing to BID or adding an ACEI (Lisinopril) 10 mg PO daily to achieve BP goals.
- Home BP Monitoring: Arrange for the patient to monitor BP at home.
- Baseline Measurements: Obtain lipid panel and HbA1c.
- Nutritional Consultation: Recommend a consultation for weight loss.
Sleep Apnea:
- Referral: Refer for CPAP assessment and fitting.
- Lifestyle Modification Counseling: Advise on reducing alcohol intake, weight reduction, and smoking cessation.
Patient Lifestyle Counseling:
- Dietary Recommendations: Advise on reducing fats and salt intake, and increasing potassium-rich foods. Recommend weight loss of 13 pounds.
- Avoidance of NSAIDs: Minimize renal injury risk.
- Smoking Cessation: Reduce atherosclerosis risk.
- Follow-Up: BP assessment in 2 weeks, with regular follow-up thereafter.
