Fisher's Snoring

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Fisher's Snoring by Mind Map: Fisher's Snoring

1. investigations

1.1. BP measurment

1.2. fundoscopy

1.3. ECG

1.4. ECHO

2. Step1: identify cues and difficult words

2.1. A/ identify cues

2.1.1. over weight 58 yomale

2.1.2. hypertensive for 10 yrs , on treatment

2.1.3. snoring

2.1.4. general lack of energy

2.1.5. worried about BP medication

2.1.6. over last 5 yrs

2.1.6.1. change the distance of driving on work

2.1.6.2. gainning weight

2.1.6.3. loss of interest

2.2. B/ difficult words

2.2.1. long haul: long distance

3. Step2: problem formulation

3.1. 58 yo hypertensive, overweight male patient, presented with worrying of snoring and general lack of energy.

4. Step3: hypothesis generation

4.1. suspected underlying cause for hypertension. stroke , kidney problems(Adeeb)

4.2. the HTN medications are the cause of loss of interest and depression (Sulami)

4.3. all the symptoms are consequences of exposure to poisons facing in his work as a truck driver(Ghannam)

4.4. tending to sleep as consequence of his condition forced him to do some changes in his work (hassan)

4.5. use of substances to be awake for long time may cause HTN

4.6. the weight gained is bcz the edema that caused by kidney problem affected HTN(homoud)

4.7. caffien is the cause of HTN. gaining weight bcz the medecations.(essam)

4.8. gaining weight>>snoring. working time changes>>lack of energy. phsychological problem may be (faris)

4.9. work requirements > low muscular tone> affecting breath while sleeping > snoring . both aggrevates each other(kashi)

4.10. hear failure and LVH are complications(adeeb)

5. Step4: hypothesis organization

5.1. primary

5.1.1. HTN

5.1.1.1. causes

5.1.1.2. risk factors or aggrevating factors

5.1.1.3. consequences(short and long term)

5.1.2. snoring and general lack of energy

5.2. secondary

5.2.1. dysfunctional impact

5.2.2. less interest

6. Step5: learning objectives

6.1. 1-to know about HTN(definition, causes, risk factors, types, manifestation, mechanisms and complications)

6.1.1. emphasis on relation between HTN and OSA

6.2. 2-complications of antihypertensive drugs

6.3. 3- criteria of diagnosing depression.

7. Step6 : review

7.1. 1-to know about HTN(definition, causes, risk factors, types, manifestation, mechanisms and complications)

7.1.1. definition

7.1.1.1. Isolated HTN

7.1.1.1.1. Grade 1

7.1.1.1.2. Grade 2

7.1.1.2. HTN

7.1.1.2.1. Grade 1

7.1.1.2.2. Grade 2

7.1.1.2.3. Grade3

7.1.1.3. MORE THAN ONE READING ARE NEEDED TO CONFIRM THE diagnosis of HTN

7.1.1.3.1. 2 or more reading

7.1.1.3.2. comparing the both arms

7.1.1.3.3. also, compare with a normal person

7.1.2. causes

7.1.2.1. essential HTN

7.1.2.1.1. unknown cause

7.1.2.1.2. multifactorial

7.1.2.2. Secondary HTN

7.1.2.2.1. renal

7.1.2.2.2. endocrine

7.1.2.2.3. drugs

7.1.2.2.4. cohn's syndrom

7.1.2.2.5. pregnancy

7.1.2.2.6. vascular disease

7.1.2.2.7. coarctation of the aorta

7.1.2.2.8. low sodium intake

7.1.2.2.9. metabolic syndrome

7.1.3. types

7.1.4. manifestation

7.1.4.1. mostly asomptomatic

7.1.4.2. headache

7.1.4.3. blurred vision

7.1.4.4. angina(in some patients)

7.1.4.5. dizziness

7.1.4.6. sweating

7.1.4.7. palpitation

7.1.5. complications

7.1.5.1. angina

7.1.5.2. hypoperfusion to the kidney

7.1.5.2.1. renal infraction

7.1.5.2.2. sodium retention

7.1.5.3. heart failure

7.1.5.4. retinopathy

7.1.5.5. stroke

7.1.5.6. malignant hypertension

7.1.6. mechanism

7.1.6.1. BP=COP IN P.resistance

7.1.6.2. increase in after load

7.1.6.2.1. sympathetic activation

7.1.6.2.2. increased volume

7.1.6.2.3. stenosis of the artery

7.1.6.3. more contraction

7.1.6.3.1. chamber enlargment

7.1.6.4. return to eccentric LVH (on long term)

7.1.6.5. arterioles are most affected

7.1.6.6. new set point

7.1.6.6.1. increase COP

7.2. 2-complications of antihypertensive drugs

7.2.1. diuretics

7.2.1.1. HYPOkalemia

7.2.2. ACEI

7.2.2.1. coughing

7.2.2.2. nasuea

7.2.3. AT1 antagonist

7.2.4. Ca channel blockers

7.2.4.1. ankle edema and constipation

7.2.5. beta blocker

7.2.5.1. bradychardia, fatique

7.2.6. alpha1 adrenoceptor antagonist

7.2.6.1. p.hypotension

7.3. 3- criteria of diagnosing depression.

7.3.1. ICD-10 CRITERIA

7.3.2. DSM-IV CRITERIA

8. Step 7: inquiry plan

8.1. present history

8.1.1. diagnosed hypertensive 13 years ago

8.1.2. snoring become noiser over the last 6months

8.1.3. 185cm, 91kg

8.1.4. play tennis most of the time

8.1.5. 25cigarittes since age 15

8.1.6. amlodipine and carvesidwas described two yrs ago

8.1.7. BP=165/105 after addition of treatment

8.1.8. 150/100 is BP 6 months ago

8.1.9. carviside

8.1.10. less intresen in

8.1.11. lethargy

8.1.12. fall asleep in a day time

8.2. past history

8.2.1. no surgical history

8.3. family history

8.3.1. both of his parents are dead

8.3.2. his sister died from stroke

8.4. personal and social history

8.4.1. atenelol 1mg

8.4.2. 3 shooners per night and more on weekend

8.4.3. now is122 kg

8.5. vital signs

8.5.1. 165/105

8.5.2. 80/m PR

8.5.3. RR 20/M

8.5.4. TM= 37

8.6. PHYSICAL EXAMINATION

8.6.1. cardiac apex beat not palpable

8.6.2. no murmurs,

8.6.3. jvp=2cm

8.6.4. 2 cm liver palpable below the costal margin

8.6.5. unattentive

8.6.6. grade retinopathy

9. Step 8: diagnosis

9.1. LVH and ischemia

9.2. OSA

9.3. HTN

9.3.1. INCREASED PREPHERAL RESISTANCE

10. objectives

10.1. managment of complicated HTN(LVH and ishcemia)

10.2. epidemiology of HTN

10.2.1. 25.5%

10.2.2. in 1999 was 22-24 %

10.3. managment of OSA

11. step9:review

12. step10:managment

12.1. HTN

12.1.1. NON PHARMACOLOGICAL

12.1.1.1. goal less than 140/90

12.1.1.2. modifying risk factors

12.1.1.2.1. obecity

12.1.1.2.2. diabetes

12.1.1.2.3. sedentary life style

12.1.1.2.4. alcohol consumption

12.1.1.2.5. regular aerobic exercise

12.1.1.2.6. low sodium intake

12.1.1.2.7. physical therapy

12.1.2. pharmacological

12.1.2.1. younger than 55

12.1.2.2. more than 55

12.1.2.2.1. step1

12.1.2.2.2. step2

12.1.2.2.3. step3

12.1.2.2.4. step4

12.1.2.3. acei +diuretics(thiazide)+b blocker+CCB are recommended for the this patient

12.1.2.3.1. start with low dose

12.1.2.4. diuretics

12.1.2.4.1. hypokalemia and hyponatremia

12.1.2.4.2. thiazide and thiazide like diuretics are good choice in HTN

12.1.2.5. acei

12.1.2.5.1. cough

12.1.2.5.2. hypotension

12.1.2.6. CCB

12.1.2.6.1. generalized edema

12.1.2.6.2. constipation

12.1.2.7. alpha blocker

12.1.2.7.1. decrease the peripheral resistance

12.1.2.8. ganglionic blocker in HTN crisis

12.1.2.9. in the presence of adverse effects, it is better to change the treatment instead of adding other drugs

12.1.2.10. ARB is effective in decreasing LVH than b blocker

12.2. OSA

12.3. renal artery stenosis

12.3.1. hypoperfusion

12.3.2. causes

12.3.2.1. atheromatous plaque

12.3.2.2. fibromuscular dysplasia

12.3.3. managment

12.3.3.1. stent

12.4. depression

12.4.1. serotonin reuptake inhibitors

13. step 11: feedback

14. resources

14.1. 1- medscape

14.2. 2- kumar

14.3. 3- emedicine.com

14.4. 4- davidson