1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.3. 30 minutes
1.3.1. The scribe does not have to write in this step!
2. Step 8
2.1. Diagnostic decision
2.1.1. uncontrolled Hypertension
2.2. Mechanism
2.2.1. Idiopathi causing increase in BP-> leading to complications like OSA, Grade II retinopathy, LVH.
2.3. Presentation
2.3.1. Fatigue, loss of interest, snoring
2.3.2. decrease in sexual function
2.4. Supporting data
2.4.1. High hemoglobin
2.4.2. ECG findings
2.4.2.1. LVH, PVC, nonspecific ST changes
2.4.3. Increase in urea and cholestrol
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. 58 y/o truckdriver, his wife made him come to the doctor because of snoring and general lack of energy and he's hypertensive
3.1.1.2. Although he has always snored a little over the past 2-3 years, this has increased in the past 6 months. for hypertension->2 yrs ago->amlopedine was added. carpazide was added 6 months ago.
3.1.1.3. his snoring is loud, his wife has moved to the son's bedroom.
3.1.1.4. noted to have hypertension 14 years ago during a routine examination
3.1.1.4.1. 185 cm/91 kg (15 years ago)
3.1.1.4.2. he used to go play tennis
3.1.1.5. when hypertension was first diagnosed, he stopped smoking, and he reduced alcohol, also was on Beta blocker->hypertension was controlled
3.1.1.6. JUST snoring(no apnea)
3.1.1.7. He does not want to have sex with his wife
3.1.1.8. Inspite of the 3rd drug, hypertension is not controlled.
3.1.1.9. No morning headache, no sweating, no palpitations
3.1.1.10. He falls asleep infront of the TV everynight
3.1.1.11. She's worried about his lack of interest
3.1.1.12. Steadely gaining weight over the past years.
3.1.1.13. Now his weight is 122 KG
3.1.2. Previous medical / surgical history
3.1.2.1. No history of renal diseases, no diabetes
3.1.2.2. Vists the dr. twice a years.
3.1.2.3. He's compliant in terms of vists and drugs
3.1.2.4. No prevoius operations
3.1.3. Drug history / allergy
3.1.3.1. No
3.1.4. medications
3.1.4.1. beta blocker
3.1.4.1.1. atenolol 100
3.1.4.2. duritic
3.1.4.2.1. carvizide
3.1.4.3. amlodipin CCB
3.1.4.3.1. 10 mg per day
3.1.5. Social / occupational history
3.1.5.1. 2-3 chooners of beer untill 6 months ago.
3.1.5.2. currently atleast 3!
3.1.5.3. 25 cigarrates a day until age 44
3.1.5.4. resumed smoking 8 months ago(a pack aday)
3.1.5.5. Found the job stressfull, found it difficult to be awake
3.1.5.6. They live at their own home. One son, one daughter
3.1.6. Family history
3.1.6.1. his hister,63,hyperlipidemia, 2 MIs
3.1.6.2. other sister died of stroke at 63
3.1.6.3. father died of 2nd MI at age 55
3.1.6.4. his mother died young for cancer of ovaries
3.1.7. Systemic review
3.1.8. Physical examination
3.1.8.1. Vital signs
3.1.8.1.1. Weight
3.1.8.1.2. height
3.1.8.1.3. pulse
3.1.8.1.4. BP
3.1.8.1.5. Temp
3.1.8.1.6. RR
3.1.8.2. CV examination
3.1.8.2.1. Cardiac apex, not palpable
3.1.8.2.2. JVP normal
3.1.8.2.3. hearts sounds
3.1.8.2.4. no periphrel edema
3.1.8.3. Liver
3.1.8.3.1. 2cm firm liver edge
3.1.8.3.2. liver span
3.1.8.4. Respiratory
3.1.8.4.1. Chest clear
3.1.8.4.2. Percussion
3.1.8.4.3. Trachea is in the middle line
3.1.8.5. Neurological
3.1.8.5.1. Optic fundi
3.1.8.5.2. retinopathy: grade II hypertensive with arterivenous niping
3.1.9. tests results
3.1.9.1. CBC
3.1.9.1.1. Hemoglobin is elevated
3.1.9.2. Chest xray was norma
3.1.9.3. Biochem
3.1.9.3.1. elevated cholestrol and urea
3.1.9.4. Trace of proteins is normal
3.1.9.5. ECG
3.1.9.5.1. LVH, Left axis deviation
3.1.9.5.2. PVC