family medicine history/pe

7/27/2019 Family Medicine History/PE

1/14

General Data: R.B, 44 years old, male, married, Filipino, Born

Again Christian, born on January 31, 196, !urrently

residing at 1" Anti#ue $t. Bago Bantay, %ue&on City

sought !onsult 'or the 'irst time at our institution on

(ar!h ), **+.

Chief Complaint: heada!he

History of Present Illness:

1 day prior to !onsultation, patient eperien!ed heada!he.

-eada!he is not aggraated by any 'a!tors, o!!urring at any time o' the day,

des!ribed as pulsating in !hara!ter, lo!ali&ed in the temporal area, non/

radiating, tolerable, lasting 'or approimately an hour and relieed by rest

and sleep. -eada!he is asso!iated 0ith nape pain and not asso!iated 0ithomiting, blurring o' ision, numbness, loss o' !ons!iousness, diaphoresis,

di&&iness, di''i!ulty o' breathing, !hest pain, impaired memory and slurring

o' spee!h. atient sel'/medi!ated 0ith metoprolol tartate 2eoblo! )*5mg

and itamin B/!omple 'or heada!hes 0hi!h a''orded no relie' o' heada!he.

ersisten!e o' heada!he prompted patient to see7 !onsult at our institution.

Interval History:

3 years prior to !onsultation, patient eperien!ed heada!he.-eada!he is not aggraated by any 'a!tors, des!ribed as pri!7ling in

!hara!ter, non/radiating, lo!ali&ed in the temporal area, tolerable, o!!urring

sporadi!ally, lasting 'or approimately 3*/minutes, at eery other month

interals. -eada!he is asso!iated 0ith nape pain. -eada!he is not asso!iated

0ith omiting, diaphoresis, di&&iness, di''i!ulty o' breathing, !hest pain,

blurring o' ision, numbness, 0ea7ness, impaired memory or slurring o'

spee!h. -eada!he is relieed by rest and sleep. atient sel'/medi!ated 0ith

para!etamol 2Biogesi! 0hi!h a''orded temporary relie' o' heada!he. o

!onsult done and heada!he persisted.

1 year prior to !onsultation, patient eperien!ed same symptoms as

des!ribed aboe 0ith heada!hes lasting 'or an hour long o!!urring eeryday.

8n!rease in number o' heada!he episodes prompted !onsult at (C

-ospital. atient 0as diagnosed as hypertensie and pres!ribed the

'ollo0ing maintenan!e medi!ation by attending physi!ian:

(etoprolol 2eoblo! )* mg5tablet, ;


2/14

Aspirin +* mg5table, ; @ag re'le, uula is mid/line

C! 'I:

atient 0as able to shrug5eleate shoulder against resistan!e. ?he head

0as resistant

0hen laterally rotated.

C! 'II:

?ongue in the midline, no atrophy, nor hypertrophy. o tongue

deiation.

Cere.ellar F"nction Absen!e o' intention tremors. Alternating supination and pronation,

point/to/point

moements, and heel to sheen test 0ere normal.

Motor System

o mus!ular atrophy, no tremors, no inoluntary moements.

ormotoni!

mus!le strength.

Sensory

Can 'eel pinpri!7, light tou!h and ibration.

-as good position sense and inta!t stereoagnosia and graphesthesia.

Deep $endon Refle)es: all normoa!tie D >

Di)2Hallpike $est: 2/ nystagmus

*is"al -c"ity:

in/-ole ?est: ;< ;$ ;< ;$

*5) *54* *53*

*54* /1


7/14

-ssessment: -ypertension $tage 1

Grror o' re'ra!tion

Plan:

H For -ypertensie 0or7/up: CBC and rinalysis

GC@, Chest I/ray 2A

a, >, Ca, Cl, B, Crea

For ?C, ?@, -


8/14

-ypertension is a disease due mostly to problems in the blood essels in 0hi!h

there is a 'un!tional and stru!tural !hanges in the as!ulature. ?he !onse#uen!es o' su!h

stru!tural !hanges !an lead to a!!elerated atheros!lerosis, hyaline and hyperplasti!

arterios!lerosis.

?he magnitude o' the arterial pressure is dependent on t0o hemodynami!

'a!tors: !ardia! output and total peripheral resistan!e. ?otal peripheral resistan!e is

a!!ounted 'or by resistan!e in the arterioles, predominantly to lumen si&e1. ?he lumen

si&e is determined by the thi!7ness o' the arteriolar 0all 0hi!h is a''e!ted by hormonal or

neuronal in'luen!es that !ause the arterioles to either dilate or !onstri!t. ?he

aso!onstri!ting 'a!tors are angiotensin 88, !athe!holamines, thromboane, leu7otrines

and endothelins. asodilators are 7inins, prostaglandins and nitri! oide. ?hese mediators

asodilate or !onstri!t blood essels by atta!hing to spe!i'i! !ell re!eptors on the sur'a!e

o' smooth mus!les. =a!ti! a!id, hydrogen ions, and adenosine are also lo!al asodilators.

Autoregulation, a pro!ess by 0hi!h in!reased blood 'lo0 to essels lead to

1$!hoen, Frederi!7. : Blood essels. 8n Robbins Pathologic Basis of Disease, )th ed. hiladelphia, LB

$aunders Co., 1994, p.4+) to 4+6.


9/14

aso!onstri!tion, is an important property to resistan!e essels. 8t is an adaptie

me!hanism that prote!ts 'lo0 'rom hyperper'usion. =o!al leels o' adenosine mediate

autoregulation and eentually leads to in!reased !ardia! 0or7load, redu!tion in !ardia!

output, and !orre!tion o' hyper'usion. Arterial hypertension is !onsidered as a disease

dependent on 'a!tors that may alter the relationship bet0een blood olume and total

arteriolar resistan!e.

?he 7idneys play an integral role in blood pressure regulation by three pro!esses.?he 'irst deals 0ith the renin/angiotensin system. Renin produ!tion in the 7idney 'orms

angiotensin 88, 0hi!h alters blood pressure by in!reasing peripheral blood resistan!e and

blood olume. Angiotensin 8 !auses aso!onstri!tion through dire!t a!tion on the smooth

mus!le 0all 0hile angiotensin 88 !auses aso!onstri!tion by stimulation o' aldosterone

se!retion in the distal tubule thus in!reasing re/absorption o' sodium and 0ater. ?he

se!ond me!hanism deals 0ith sodium homeostasis. $odium homeostasis is regulated by

the glomerular 'iltration rate 2@FR and @FR/independent natriureti! 'a!tors. Lhen

blood olume is redu!ed, the @FR 'alls, thus leading to in!reased re/absorption o'

sodium by proimal tubules in an attempt to !onsere sodium and epand blood olume.

Atrial natriureti! 'a!tor 2AF also a @FR dependent 'a!tor is a group o' peptides that is

se!reted by heart atria in response to olume epansion. 8t inhibits sodium re/absorption

in the distal tubules and !auses asodilation. ?he third me!hanism deals 0ith renal

asodepressor substan!es. ?he 7idney produ!es a ariety o' asodepressor or

antihypertensie substan!es 0hi!h in!lude prostaglandins, a urinary 7alli7rein/7inin

system, platelet/a!tiating 'a!tor and nitri! oide.

Classi'i!ation o' hypertension is based on the M$eenth Report o' the Joint

$!hoen, Frederi!7. : Blood essels. 8n Robbins Pathologic Basis of Disease, )th ed. hiladelphia, LB

$aunders Co., 1994, p.4+) to 4+6.


10/14

ational Committee on reention and


11/14

$a.le 3: Classification and Mana&ement of .lood press"re for ad"lts

#P

Classification

S#P

mm H&

D#P

mm H&

,ifestyle

Modification

4itho"t

Compellin&

Indication

5initial dr"&

therapy6

4ith

Compellin&

5initial dr"&

therapy6

!ormal N1* N+* en!ourage o

antihypertensie

drug indi!ated


12/14

alidated instrument should be used. ersons should be seated #uietly 'or at least )

minutes in a !hair 2rather than on an eam table, 0ith 'eet on the 'loor, and arm

supported at heart leel. (easurement o' B in the standing position is indi!ated

periodi!ally, espe!ially in those at ris7 'or postural hypotension. An appropriate/si&ed

!u'' 2!u'' bladder en!ir!ling at least +*Q o' the arm should be used to ensure a!!ura!y.

At least t0o measurements should be made. $B is the point at 0hi!h the 'irst o' t0o or

more sounds is heard 2phase 1 and


13/14

$a.le 9( $ar&et /r&an Dama&e

Heart

=e't entri!ular hypertrophy

Angina or prior myo!ardial in'ar!tion

rior !oronary reas!ulari&tion -eart Failure

#rain

$tro7e or transient is!hemi! atta!7

Chronic idney Disease

Peripheral -rterial Disease

Retinopathy

Routine laboratory tests re!ommend be'ore initiating therapy in!lude an

ele!tro!ardiogram, urinalysis, blood glu!ose and hemato!rit, serum potassium, !reatinine

2or the !orresponding estimated glomerular 'iltration rate @FRS, and !al!ium and lipid

pro'ile, a'ter a 9/1 hour 'ast, that in!lude high density lipoprotein !holesterol, lo0

density lipoprotein !holesterol, and trigly!erides. ;ption tests in!lude measurement o'

urinary albumin e!retion or albumin5!reatinine. (ore etensie testing 'or identi'iable

!auses is not indi!ated generally unless B !ontrol is not a!hieed.


14/14

$a.le ;( ,ifestyle Modifications to mana&e hypertension

Modification Recommendation -ppro)imate S#P

Red"ction 5ran&e6

Leight redu!tion (aintain normal body0eight 2body mass inde

1+.) to 4.9 7g5mE

)/* mm -g51* 7g 0eightloss

Adopt

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